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Page 2
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Page 3
Copyright © 2006 by F. A. Davis.
OB
Peds
Women’s Health
Notes
Nurse’s Clinical Pocket Guide
Brenda Holloway, CRNP, FNP, MSN
Cheryl Moredich RNC, MS, WHNP
Kathie Aduddell, Ed.D, MSN, RN-BC
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A Davis’s Notes Book
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Copyright © 2006 by F. A. Davis.
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Copyright © 2006 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be
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As new scientific information becomes available through basic and clinical
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Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique
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GYN
ANTE- INTRA- POSTPEDS
PEDS
BASICS PARTUM PARTUM PARTUM BASICS ASSESS
MEDS/
ACUTE
TOOLS
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Copyright © 2006 by F. A. Davis.
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Page 6
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Page 1
Copyright © 2006 by F. A. Davis.
1
Nurses Impact the Health
of Women Through
■
■
■
■
■
Educating women about healthy lifestyle choices
Role modeling healthy behavior and promoting wellness
Describing the role of prevention and early detection
Informing women about disease treatment and progression
Being an advocate and resource for community referrals
Cervical/Gynecological Health
■ According to the guidelines of the American College of
Obstetrician and Gynecologists (ACOG) and the American
Cancer Society (ACS), initial cervical screen for cancer should
begin 3 years after first sexual intercourse or by age 21,
whichever comes first
■ However, ACOG recommends that a visit to an
obstetrician/gynecologist occur before that time for health
guidance, screening, and prevention
■ Follow-up cervical screen for low-risk women less than
30 years of age
ACOG Guidelines
ACS Guidelines
Annually
Annually with conventional Pap
smear
Every 2 years with liquid-based
cytology
■ Women 30 years of age and older, with three consecutive
negative cervical screens, are recommended to have repeat
exams every 2–3 years
GYN
BASICS
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GYN
BASICS
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Page 2
Copyright © 2006 by F. A. Davis.
Sexually Transmitted Infections (STIs)
■ Abstinence from sexual activity (both oral and genital) is the
only 100% effective method of STI prevention
■ Consistent and proper use of condoms during sexual
intercourse will decrease the incidence of STIs
■ STIs transmitted via skin contact (human papillomavirus
[HPV], herpes simplex virus [HSV]) may still be transmitted
with use of latex condoms
■ Sexual partners should be tested and treated when an STI is
identified; sexual activity should be avoided until treatment
regimen completed
■ Patients diagnosed with a viral STIs should consult their
health-care provider for long-term management
■ Reportable STIs must be forwarded to the local health
department along with treatment rendered
■ Encourage immunization against hepatitis B
■ Visit CDC Web site www.cdc.gov for latest treatment
guidelines for STIs
(Continued text on following page)
2
Copyright © 2006 by F. A. Davis.
Infection
Gonorrhea
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Chlamydia
Trichomoniasis
Hepatitis
Human Papilloma
Virus (HPV)
Symptoms (May be asymptomatic)
Yellow-green vaginal discharge
Dyspareunia
Abdominal pain
Dysuria
Mucopurulent discharge
Postcoital bleeding
Dyspareunia
Abdominal pain
Dysuria
Frothy malodorous vaginal discharge
Dyspareunia
Vaginal itching/irritation
Dysuria
Fatigue
Dark urine
Clay-colored stool
Jaundice/abdominal pain
Many subtypes exist, some associated
with cervical dysplasia
Visible wartlike growths in genital area
associated with subtypes 6, 11
Detection
Endocervical culture
Urine test
Endocervical culture
Urine test
Saline wet mount of vaginal
discharge viewed under
microscopy
Serological testing
Pap smear report
Colposcopy/biopsy
(Continued text on following page)
GYN
BASICS
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Sexually Transmitted Infections (STIs) (Continued)
Primary
Chancre (painless raised ulcer)
Secondary
Skin rash, lymphadenopathy
Latent
Lacking clinical manifestations
Tertiary
Cardiac, ophthalmic, auditory
involvement
HIV
Fever
Malaise
Lymphadenopathy
Skin rash
Herpes Simplex
Virus (HSV)
Painful, recurrent vesicular lesions
Fever, malaise
Enlarged lymph nodes
GYN
BASICS
Detection
Serological testing
Nontreponemal (RPR, VDLR)
■ Reported quantitatively
(titers)
■ Four-fold change in titers
clinically significant
■ Effective treatment will result
in falling titers
■ False-positive possible; verify
with treponemal test
Treponemal (FTA-ABS)
Reported as positive or negative
Serological testing
(Pretest and posttest counseling
with informed consent
required)
Positive screen must be
confirmed by more specific
test (Western blot)
Viral culture with DNA probe
4
Copyright © 2006 by F. A. Davis.
Page 4
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Symptoms (May be asymptomatic)
Syphilis
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Sexually Transmitted Infections (STIs) (Continued)
Infection
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Page 5
Copyright © 2006 by F. A. Davis.
5
Breast Health
■ Monthly breast self-exam, starting at age 20, instructed to
woman as an optional tool for identifying and reporting
breast changes
■ Clinical breast exam at least every 3 years (age 20–40) during
a physical exam by a health professional; yearly after age 40
■ Annual mammogram starting at age 40
Instructions for Breast Self Exam (BSE)
Step 1: Inspection
1. Visually inspect the breasts, looking for dimpling, lumps, skin
irregularities, symmetry
2. Visually inspect in several positions; may accentuate an
abnormality
◆ Hands at the side
◆ Hands above the head
◆ Hands pressed onto hips
◆ Leaning over
BSE positions. (From Dillon PM. (2003) Nursing Health Assessment: A
Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 459.)
GYN
BASICS
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BASICS
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Page 6
Copyright © 2006 by F. A. Davis.
Step 2: Palpation
1. Feel the breast tissue and lymph node chain for lumps or
thickening by using three finger pads while exerting light,
medium, and deep pressure in a systematic fashion
BSE palpation patterns. (From Dillon PM. (2003). Nursing Health
Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A.
Davis, p 461.)
6
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Copyright © 2006 by F. A. Davis.
7
2. Begin by lying down on a flat surface with arm raised and a
folded towel under the back of the breast being examined
3. After examining breast tissue, bring arm toward body and feel
the axilla and the skin above as well as below the collar bone
4. Repeat technique on the other side
5. Report lumps, thickening, nipple discharge or any suspicious
findings to health-care provider
Preconception Counseling
Preconception counseling should be included in health screenings for all women of childbearing age and focus on factors that
impact organogenesis.
■ Discuss chromosomal abnormalities associated with
advanced maternal age
■ Incorporate 400 mcg of folic acid daily (for low-risk women)
■ Avoid alcohol, smoking, and drug use
■ Teach prevention of sexually transmitted infections
■ Update immunizations and investigate rubella titer
■ Review exposure to environmental risk factors
■ Control of chronic medical conditions
■ Review classification of prescribed medication
Family Planning Options
■ Educate women on available family planning methods,
discussing the risks, benefits, and efficacy of each method
■ Efficacy of each method influenced by correct and consistent use, user preparedness, motivation, dexterity, and
comorbidities
■ Educate women on the process of menses
■ The menstrual cycle is a cyclic feedback system occurring
approximately every 28 days with the first day of menses
being day 1
■ Low levels of estrogen and progesterone stimulate the
hypothalamus to secrete gonadotropin-releasing hormone
(GnRH), which stimulates the anterior pituitary to release
GYN
BASICS
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GYN
BASICS
■
■
■
■
■
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Page 8
Copyright © 2006 by F. A. Davis.
follicle stimulating hormone (FSH), encouraging maturation
of the Graafian follicle
Estrogen, produced by the maturing follicle, causes the
endometrial lining to proliferate
The mid-cycle release of luteinizing hormone (LH) from the
anterior pituitary promotes release of the mature ovum
(ovulation)
Once ovulation occurs, the corpus luteum (remaining cells
of the follicle) produces estrogen and progesterone, which
stimulates endometrial thickening
If conception does not occur, the corpus luteum regresses, causing a decrease in estrogen and progesterone,
and ischemic changes to the functional layer of the
endometrium
The menstrual cycle is divided into phases of the ovarian
and endometrial cycle:
Ovarian Cycle
Endometrial Cycle
Menstrual
Follicular
Ovulatory
Luteal
Menstrual
Proliferative
Secretory
Ischemic
Sexual Abstinence
■ Refraining from sexual activity is the only 100% effective way
to prevent pregnancy
Fertility Awareness Methods
■ Teaches familiarity with body in order to recognize signs of
fertility
■ Useful to avoid or achieve pregnancy, as well as monitor
gynecological health
■ To prevent pregnancy, couples abstain during recognized
period of fertility
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Page 9
Copyright © 2006 by F. A. Davis.
9
Cervical Mucus
Amount and character of cervical mucus changes throughout the
menstrual cycle in response to hormones
■ Following menses, cervical mucus scant, thick, and cloudy
■ At ovulation, cervical mucus becomes more abundant,
slippery, clear, and stretchable in response to estrogen
(known as “spinnbarkeit”), promoting sperm motility;
increased likelihood of pregnancy with unprotected
intercourse
■ After ovulation, cervical mucus scant, thick, cloudy, and is no
longer stretchable
■ Cervical mucus should be evaluated and charted daily
Basal Body Temperature (BBT)
■ Monitor and graph BBT daily before rising
■ Prior to ovulation, BBT decreases slightly in response to
estrogen
■ After ovulation, a surge of progesterone increases BBT by
0.5–1.0F
■ BBT remains high with conception, but falls without
conception, prior to menses
■ Certain activities may alter BBT: smoking, use of electric
blanket or heated waterbed, restless sleep, illness
Calendar Method
■ Based on assumption that ovulation occurs 14 days before the
onset of menses
■ Record menstrual cycles for 6–8 months
■ Calculate fertile period
Subtract 18 from the shortest menstrual
cycle (28 18 10)
Subtract 11 from the longest menstrual
cycle (32 11 21)
Days 10–21 fertile time; abstain from intercourse
GYN
BASICS
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BASICS
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Page 10
Copyright © 2006 by F. A. Davis.
Lactation Amenorrhea Method (LAM)
■ Prolactin suppresses follicle stimulating hormone (FSH), and
therefore suppresses ovulation
■ Postpartum woman who exclusively breastfeed during the
first 6 months after childbirth, including at least one night
feeding, may postpone ovulation
■ Instruct patients that ovulation and return of fertility may
occur before first menses with a risk of unintended pregnancy
Barrier Methods
Prevents conception by blocking entry of sperm into the cervix
Diaphragm
■ Dome-shaped rubber cup with a flexible ring that fits over the
cervix; regularly examine integrity of rubber
■ Inserted with spermicide applied to dome before intercourse
and left in place for at least 6 hours after intercourse
■ Should not be left in place more than 24 hours due to risk of
toxic shock syndrome
■ Additional spermicide may be added with diaphragm still in
place for repeated intercourse
■ Diaphragm is custom fitted and must be refitted with 20 pound
weight change and after a vaginal birth
■ Urinary tract infections (UTI) more common with diaphragm
use; teach to report symptoms of UTI
■ Wash with soap and water after each use; inspect integrity of
rubber by holding up to light to inspect for holes
Male Condom
■ Thin latex sheath that covers the erect penis during sexual
intercourse
■ Provides protection from STIs
■ Space should be left at the end of the condom for ejaculate
■ Hold condom at base of the penis upon withdrawal to prevent
spillage
■ Only water-soluble gel should be used for lubrication to prevent degradation of the latex
10
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Copyright © 2006 by F. A. Davis.
11
■ New condom should be used with each act of intercourse
■ Store in unopened package in cool, dry place
Female Condom
■
■
■
■
■
■
Prelubricated polyurethane sheath with two flexible rings
Inner ring helps with insertion and covers the cervix
Outer ring rests on vulva
Water or oil-based lubricant and spermicide may be used
Can be stored at any temperature; 5-year shelf life
Remove prior to standing by twisting the outer ring to contain
semen and pull out
■ Material degradation could occur if both male and female
condoms used simultaneously
Hormonal Methods
Hormonal contraceptives
Hormonal contraceptives alter the normal menstrual cycle,
inhibiting ovulation, altering the endometrial lining, and
thickening cervical mucus.
■ Mechanism of Action
■ Effects of Estrogen
• Ovulation inhibited by suppression of follicle stimulating
hormone (FSH) and luteinizing hormone (LH)
• Endometrial lining altered making the endometrium less
receptive to implantation
■ Effects of Progestin
• Cervical mucus thickened, hampering sperm transport
• Suppression of midcycle LH peak prevents ovulation
• Decreases cilia movement within the fallopian tube
■ Advantages of hormonal contraceptives include decreased
dysmenorrhea, decreased menstrual blood loss, and reliability
■ Requires addition of condom for STI protection or as back-up
with user error
■ Side effects may include nausea, vomiting, breast tenderness,
breakthrough bleeding, headaches, mood changes, decreased
libido, or weight change
GYN
BASICS
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BASICS
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Copyright © 2006 by F. A. Davis.
■ May cause serious health issues; advise hormonal contraceptive users not to smoke and teach reportable symptoms
of possible complications:
■ Abdominal pain (severe)
■ Chest pain
■ Headache (severe)
■ Eye problems (blurred, double vision)
■ Severe leg pain, redness, and swelling
■ Shortness of breath
■ Worsening depression
■ Jaundice
■ Contraindications to hormonal contraceptives
■ History of heart attack, stroke, blood clot; estrogen
promotes blood clotting
■ History of breast or female reproductive cancer; tumors
may be hormonally provoked
■ Diabetes with vascular involvement; estrogen promotes
blood clotting
■ Impaired liver function; OCs are metabolized through the
liver and use may adversely affect existing liver disease
■ Suspected or confirmed pregnancy
■ Uncontrolled hypertension; increased risk for
cardiovascular complications
■ Smoker over 35 years of age; increases the risk for cardiovascular complications
■ History of migraine headaches (with aura); increased risk
for stroke
■ Major surgery planned with immobilization; increased risk
for deep vein thrombosis
Combined Hormonal Methods
(Combination of estrogen and progestin)
Combination Oral Contraceptives (OC)
■ Most OCs are administered daily for 21 days, followed by
7 hormone-free days (either no pills taken or placebos taken
for 7 days)
■ Pill selection based on amount of estrogen, type of progestin,
adrenergic effect, or symptoms presented
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Copyright © 2006 by F. A. Davis.
13
■ Combined OCs may be monophasic (estrogen and progestin
remain constant) or multiphasic (hormone dosing changes
throughout the month)
■ Extended-cycle OCs are taken consistently for 12 weeks,
followed by 7 days of inert pills; withdrawal bleeding
occurring only four times per year
■ Combination hormonal contraceptives may decrease
production of breast milk and should be avoided while
breastfeeding
■ Effectiveness of OCs altered by certain medications; patients
should report use of contraceptive agents to all health-care
providers
Transdermal Patch
■ Patch applied to skin weekly for 3 weeks; fourth week is patchfree to allow withdrawal bleeding
■ Acceptable application sites include abdomen, buttocks, upper
outer arm, and upper torso (but not the breasts); site should
vary weekly
■ Application involves cleansing skin, avoiding lotion, and
firmly applying patch making sure all corners adhere to skin
■ May engage is usual activities (bathing, swimming,
exercising)
■ Partial removal and skin reactions possible
■ Decreased effectiveness noted in women who weigh more
than 198 pounds
Vaginal Ring
■ Small, flexible hormone-impregnated ring inserted and left in
the vagina for 3 weeks; removed in fourth week to allow for
withdrawal bleeding
■ Ring should be kept inside unopened package before
insertion; protect from sunlight and high temperatures
■ Side effects include increase in vaginal discharge, vaginal
irritation, or infection
■ Expulsion may occur; if out for more than 3 hours, back-up
method of birth control needed for the next 7 days
GYN
BASICS
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BASICS
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Page 14
Copyright © 2006 by F. A. Davis.
Progestin Only Preparations
■ Progestin-only preparations are indicated for women who
cannot use estrogen
■ Alteration in menstrual cycle common with progestin-only
methods
■ May be used in lactation once breastfeeding is well
established
■ Side effects include weight gain, menstrual irregularities, and
depression
Oral Contraceptives “minipill”
■ Important to take at the same time each day
■ Back-up method of birth control needed with missed or late
pills
Injectable Progestin Contraception
Depo-medroxyprogesterone (DMPA)
■ Injected by health-care provider intramuscularly (IM) every 3
months
■ Return to fertility may be delayed
■ Bone loss may be of concern with continued use; should not
be used for greater than 2 years continuous use
Intrauterine system (IUS)/Intrauterine Device (IUD)
■ Inhibits fertilization by altering fallopian tube transport of
sperm and ova, as well as producing cellular changes to the
endometrial lining
■ Recommended for parous women in a mutually monogamous
relationship with no history of pelvic inflammatory disease
(PID)
■ Inserted in office by qualified practitioner
■ Increased incidence of pelvic inflammatory disease (PID)
■ Uterine perforation and expulsion of device possible
■ Attached to string that extends outside of the cervix; instruct
patient to check for presence of string monthly
■ Teach patient the following reportable warning signs
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Copyright © 2006 by F. A. Davis.
15
Signs of IUD complications:
Period late (pregnancy)
Abdominal pain (infection)
Infection
Not feeling well (infection)
String missing (IUD expelled)
Types
1. T-shaped hormone-releasing (levonorgestrel) device placed in
the uterus to prevent pregnancy for up to 5 years
2. Copper IUD contains no hormones; continuous use for up to
10 years if no complications
Emergency Contraception (EC)
Contraceptive agents used after unprotected intercourse
intended for the prevention of pregnancy
■ Available agents
■ Copper IUD inserted within 5 days of unprotected
intercourse
■ Oral contraceptives taken at higher doses; both combination and progestin-only preparations are available
• Initial dose within 72 hours of unprotected intercourse
• Follow-up dose within 12 hours of first dose
Permanent Methods
■ Prevent conception by mechanically blocking the fallopian
tubes, preventing passage of ovum
■ Low failure rate, however, if pregnancy occurs, may be
ectopic
Tubal Ligation (Incisional Method)
■ Performed in a hospital or outpatient surgical unit under
general anesthesia
■ Fallopian tubes cut, cauterized, and/or clipped
■ Complications may include bleeding, infection, incomplete
tube closure, injury to adjacent organs, or complications from
anesthesia
GYN
BASICS
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BASICS
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Copyright © 2006 by F. A. Davis.
Hysteroscopic Tubal Sterilization (Nonincisional method)
■ Microinserts placed into the opening of the fallopian tubes,
causing scar tissue to grow in approximately 3 months
■ Performed in physician’s office or outpatient procedure lab
with local anesthetic to cervix
■ Follow-up hysterosalpingogram performed at 3 months to
ensure both tubes have been blocked; alternate method of
birth control used until tube status verified
■ Complications may include incorrect placement requiring
second or operative procedure, ectopic pregnancy, infection,
perforation of the uterus
Health Promotion in Adult Women
Cardiovascular Health Promotion
■
■
■
■
Cholesterol screening every 5 years after age 20
Blood pressure screening at each medical visit
Incorporate fitness into daily lifestyle
Discourage smoking
Promotion of Weight Management and Fitness
■ Calculate body mass index and determine goal
■ Discuss exercise regimen for current fitness level
■ Provide nutrition guidance according to the guidelines set
forth by the U.S. Department of Agriculture (USDA)
Prevention and Treatment of Osteoporosis
■ Risk increases after menopause; estrogen reduction results in
increased bone resorption
■ Discuss adequate intake of calcium and vitamin D
■ Encourage weight-bearing exercise
■ Educate concerning bone density scans
■ Discuss medications to reduce bone loss with primary healthcare provider
16
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Copyright © 2006 by F. A. Davis.
17
Early Detection of Colorectal Cancer
■
■
■
■
■
Screening starting at age 50 (ACOG, ACS)
Yearly fecal occult blood test plus
Flexible sigmoidoscopy every 5 years or
Colonoscopy every 10 years or
Double contrast barium enema every 5 years
Early Detection/Prevention of Skin Cancer
■ Use sunscreen with SPF of 15 or higher
■ Avoid sun exposure from 10 a.m. to 4 p.m. and tanning
beds
■ Perform self-evaluation of the skin; report suspicious
lesions
■ Thorough skin exam every 3 years age 20 to 39; annually
after age 40
Menopause
■ Cessation of menses with amenorrhea for 12 months
■ Symptoms
■ Vasomotor symptoms
• Hot flushes
• Night sweats
■ Urogenital symptoms
• Thin, friable vaginal mucosa
• Vaginal dryness and irritation
• Dyspareunia
■ Other Systemic Symptoms
• Sleep disturbance
• Mood swings
• Memory loss
• Skin changes
• Hair thinning
GYN
BASICS
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BASICS
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Copyright © 2006 by F. A. Davis.
Hormone Replacement Therapy (HRT)
■ The decision of whether of not to use hormone replacement
therapy should be made after careful medical evaluation and
discussion with the primary health-care provider concerning
the risk/benefit ratio for each woman
■ Current guidelines by the U.S. Food and Drug Administration
(FDA) recommend HRT use only for moderate to severe
menopausal symptoms at the lowest effective dose for the
shortest period of time, noting the risk/benefit ratio for each
woman
■ If HRT prescribed solely for vaginal/vulvar symptoms, local
hormone therapy should be considered
■ Alternatives to HRT should be considered if HRT used for sole
purpose of osteoporosis prevention
18
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Copyright © 2006 by F. A. Davis.
19
Establishing Pregnancy
■ Pregnancy may be assumed based on the presence of certain
signs and symptoms Presumptive signs are subjective and
recorded under the history of present illness
■ Probable and positive signs of pregnancy are objective and
recorded as physical assessment findings
Presumptive
Probable
Positive
Amenorrhea
Breast
tenderness
Quickening
Nausea/
Vomiting
Urinary
frequency
■ Positive pregnancy test
■ Uterine enlargement
■ Hegar’s sign (softening
of lower uterine
segment)
■ Goodell’s sign
(softening of cervix)
■ Chadwick’s sign (bluish
hue to cervix/vagina)
■ Braxton Hicks
contractions
Fetal heart beat
auscultated
Fetal movement
palpated per
practitioner
Ultrasound of
gestation
■ Urine pregnancy test
■ Reacts with human chorionic gonadotropin (hCG)
■ Performed on first voided urine sample of the day;
positive results possible before the first day of a missed
menstrual period
■ Serum pregnancy test
■ Useful in monitoring expected pattern of progression of
hCG; detects hCG as early as 9 days postconception
■ Ultrasound
■ Confirms presence of gestational sac, fetal pole, and fetal
cardiac activity
■ Validates location of pregnancy (intrauterine versus
ectopic)
ANTEPARTUM
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Estimated Date of Delivery
■ Establishing an accurate date of delivery is important to:
■ Determine timing of antenatal screening
■ Monitor growth of the fetus
■ Scrutinize timing of delivery
■ Common abbreviations denoting delivery date are:
■ EDD. …………………… estimated date of delivery
■ EDC. …………………… estimated date of confinement
■ EDB. …………………… estimated date of birth
Naegele’s Rule
■ Formula used to estimate date of delivery
■ Count back 3 months and add 7 days to the last normal
menstrual period (LNMP) reported by the patient
Example: The patient states that her LNMP was April 20th
April is the 4th month 20th day
3 months 7 days
1st month
27th day
The baby is estimated to be due on January 27th of the
following year
Trimesters of Pregnancy
Normally, pregnancy continues for 40 weeks or 280 days
1st trimester
2nd trimester
3rd trimester
conception until 12 weeks’ gestation
13 weeks until 27 weeks’ gestation
28 weeks until 40 weeks’ gestation
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21
Schedule of Prenatal Visits (low-risk pregnancy)
■ Monthly until 28 weeks’ gestation
■ Biweekly from 28 weeks until 36 weeks
■ Weekly from 36 weeks until delivery
Prenatal Health History
Performing a thorough health history in the prenatal period
is essential to planning nursing care and identifying highrisk women.
■ Medical history
■ Chronic illness
■ Current and recent medication
■ Recent acute illness
■ Childhood illnesses
■ Surgical history
■ Problems with anesthesia
■ Previous surgeries
■ Uterine/cervical surgeries
■ Obstetrical history
■ Type of deliveries: vaginal/cesarean
■ Complications with past pregnancies
■ Infertility
■ Documentation of obstetrical history
Descriptive Term
Gravida (G)
Term (T)
Preterm (P)
Abortion (A)
Living (L)
ANTEPARTUM
Definition
Number of pregnancies
Number of deliveries after 37 weeks
Number of deliveries after 20 weeks but
before 38 weeks
Number of deliveries before 20 weeks,
either spontaneous or induced
Number of living children
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Documentation Example 1: The prenatal client states having
three children at home. She reports that her son was born on
his due date, but her daughters were both born a month early.
She states that she lost a baby in her second month.
G: 5 (currently pregnant, 3 children at home, one abortion)
T: 1 (her son was born on his due date)
P: 2 (her daughters were each born a month early)
A: 1 (she lost a pregnancy at approximately 8 weeks)
L: 3 (reports three children at home)
Document as G5-1213
Documentation Example 2: The same prenatal client may also
be described as G5 (5 pregnancies) P3 (number of live births);
pregnancies ended before 20 weeks are not counted as “P” in
this method.
■ Sexual history
■ Number of sexual partners
■ Sexually transmitted infections
■ Sexual abuse
■ Methods of contraception
■ Condom use
■ Social history
■ Use of recreational drugs
■ Smoking
■ Domestic abuse
■ Educational level/ability to read
■ Economic status
■ Type of health insurance
■ Need for community referrals
• Transportation
• Nutrition
• Medications
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23
Physiological Changes in Pregnancy
Heart
rate
Cardiac
output
Blood
volume
Blood
pressure
↑
↑
↑
*
Systemic vascular
resistance
↓
*slight↓ with return to baseline by 3rd trimester
Stroke
volume
Red
blood cells
Hemoglobin
Hematocrit
White
blood cells
↑
↑
↓
↓
↑
Glomerular
filtration rate
Urine output
↑
↑
↑ Increase
Basal
metabolic rate
Respiratory
rate
↑
↓ Decrease
↔
↔ No change
Hormonal Changes in Pregnancy
Hormone
Functions
Estrogen
↑
Progesterone
↑
Human chorionic
gonadotropin (hCG)
Relaxin
↑
Prolactin
↑
Human placental
lactogen
↑
ANTEPARTUM
↑
Increase uterine muscle mass
Increase blood flow to uterus
Prepare breasts for lactation
Relax venous walls
Inhibit uterine contractions
Stimulate estrogen/progesterone
production
Discourage uterine contraction
Remodeling of collagen
Maturation of breast ducts/alveoli
Stimulate lactation
Insulin antagonist
Allow adequate glucose for fetal
demand
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Nursing Care with First Prenatal Visit
■ Determine EDD based on LNMP
■ Document current gestational age (gestational wheel is a tool
for quick reference to current gestational age)
■ Document baseline vital signs
■ Document height, weight, and body mass index (BMI)
■ Obtain urine specimen and test for presence of:
Substance
Expected Finding
Glucose
Protein
Negative/Trace
Negative/Trace
■ Auscultate fetal heart tones
■ Measure fundal height in centimeters from symphysis pubis
to the top of the fundus
■ Uterine size increases in pregnancy in a predictable pattern
and is measured to gauge fetal growth
■ Fundal height that is lagging or greater than expected
should be further investigated
Weeks’ Gestation
12
16
20
21–36
Fundal Height
Just above symphysis pubis
Halfway between symphysis pubis and
the umbilicus
At the umbilicus
Fundal height generally matches weeks
gestation in centimeters
EXAMPLE: Fundal height at 28 weeks
should be approximately 28 cm.
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25
Fundal height. (From Dillon PM. (2003). Nursing Health Assessment: A
Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p 736.)
■ Provide appropriate education for gestational age
■ Discuss procedure for lab testing
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Common
Laboratory Tests
Expected Finding
in Pregnancy
HIV *Check state laws regarding
HIV testing in pregnancy
Blood type
Rh factor
Antibody screen
Hemoglobin
Hematocrit
Platelets
WBC
RPR
Hepatitis B antigen
Rubella titer
Hemoglobin electrophoresis
Chlamydia culture
Gonorrhea culture
Pap smear
26
Negative
A, B, AB, O
Negative/Positive
Negative
11.5 mg/dL
33%
150,000–400,000 mm3
5,000–12,000 mm3
Negative
Negative
1:8 Immune
AA, unaffected
Negative
Negative
Normal cytology
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27
Diagnostic Testing in Early Pregnancy
Diagnostic Test
Ultrasound Performed
throughout pregnancy
Clinical Applications:
■ Confirm and date pregnancy
■ Verify pregnancy location
■ Detect fetal cardiac activity
■ Measure fetal growth
■ Detect fetal anomalies
■ Measure amniotic fluid index
■ Determine fetal position
■ Determine placental position
■ Measure cervical length
■ Adjunct to invasive procedures
Chorionic villi sampling (CVS)
Performed at 10–12 weeks
Clinical Application:
■ Chromosomal analysis
Amniocentesis
Performed throughout pregnancy
Clinical Applications:
■ Chromosomal analysis is
desired
■ Measure AFP
■ Measure bilirubin level
■ Determine lung maturity
■ Lecithin/Sphingomyelin
Ratio (L/S Ratio)
■ Phosphatidylglycerol (PG)
■ L/S Ratio of 2:1 and positive
PG indicative of fetal lung
maturity
Maternal Serum Triple Screen
(tests maternal serum for
AFP, hCG, and estriol)
Nursing Considerations
Position to avoid supine
hypotension; folded towel
under right hip if supine
Review blood type, Rh and
antibody status
Administer Rh (D) immune
globulin if indicated
Monitor patient for postprocedure cramping or
bleeding
Monitor fetal heartbeat
NOTE: This is a screening
method only. A positive
result suggests the need
for further testing
(Continued text on following page)
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Diagnostic Test
Nursing Considerations
Performed at 15–18 weeks
Clinical Applications:
■ Serum screen for neural tube
defects/ Down syndrome
Results adjusted according
to documented gestational
age, maternal age, race,
and weight, presence of
diabetes/multiple
gestation; the nurse must
accurately document these
variables on the
laboratory requisition
Interpretation of Results
Defect
AFP
hCG
Estriol
Risk for open
neural tube
↑
WNL
WNL
Risk for Down
syndrome
↓
↑
↓
↑ elevated ↓ decreased
WNL within normal limits
Education in the Early Prenatal Period
■ Elevated estrogen and progesterone levels in early pregnancy
generate changes in the body, causing pregnancy associated
discomforts
■ Offer suggestions to lessen discomforts
■ Teach patient to report symptoms that may indicate a potential
complication (in red)
Discomfort
Urinary
frequency
Nausea
and vomiting
Patient Education
Related to uterine position/weight
Encourage frequent emptying of bladder
Discourage limiting oral fluids
Report burning or pain with urination
Related to elevated hormone levels
Encourage small, frequent meals
Eat crackers before rising
Avoid pungent odors, spicy or greasy food
Discuss limited time frame for nausea
(subsides around 12 weeks’ gestation)
Report excessive vomiting
(Continued text on following page)
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29
Education in the Early Prenatal Period (Cont’d)
Discomfort
Emotional
lability
Leukorrhea
Breast
discomfort
Fatigue
Nasal stuffiness/
epistaxis
ANTEPARTUM
Patient Education
Related to hormone changes
Discuss normalcy of emotional changes with
patient and partner
Ambivalence normal in first trimester
Report constant crying, inability to care for
self, suicidal thoughts
Related to vasocongestion of mucous
membranes
Avoid tampon use and douching
Wear peri-pad to absorb discharge
Encourage cotton underwear
Report vaginal discharge with an odor or
color, vaginal bleeding, or leaking of
amniotic fluid
Hormone-related breast development often
first presumptive sign of pregnancy
Wear a supportive bra
Colostrum may be expressed in pregnancy
Introduce the value of breastfeeding
Introduce/reinforce breast self-exam
Report any breast lump or unusual discharge
Related to rapid hemodynamic and
metabolic changes in the first trimester
Encourage naps during the day
Encourage prenatal vitamins
Encourage healthy diet
Report syncope and vertigo
Related to vasocongestion of mucous
membranes
Increased humidity in home may help
Warm compresses to sinus area
Avoid over-the-counter (OTC) cold remedies
Report fever, green/yellow nasal discharge,
or frequent nosebleeds
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Teratogen Exposure
Teratogens are substances that are harmful to the developing fetus;
advise patient to avoid exposure.
Teratogen
Viruses
Environmental
Drugs
Patient Education
Avoid contact with ill persons
Report fever, rash, illness to primary
health-care provider
Infections causing serious harm to fetus:
Toxoplasmosis
Other (hepatitis B)
Rubella
Cytomegalovirus
Herpes simplex virus (HSV)
Avoid exposure to:
Mercury
Radiation
Lead
Other environmental toxins
Recreational
Discourage alcohol use
Encourage patient to stop smoking
Refer to smoking cessation classes
Assess use of illicit drugs
Refer to addiction counselors
Discuss the role of drug screening
Discuss adverse effects to fetus
OTC/Herbal
Caution patient to discuss use of all OTC/herbal
medications with primary health-care provider
Prescription
List all medications prescribed since LNMP on
prenatal record
Investigate drug classification in drug
guide book
Inform primary health-care provider of drug list
Record drugs/dosages on prenatal record
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31
Pregnancy Classification of Medications
Drug Class
A
B
Pregnancy Safety
No evidence of fetal risk
No animal risk demonstrated; human fetal risk
not demonstrated
Animal study demonstrates risk
No adequate study in humans
Evidence of human risk
Weigh risk/benefit ratio of drug
Definite fetal risk
Contraindicated
C
D
X
Source: U.S. Food and Drug Administration
Nutrition
■
■
■
■
■
■
Inquire about dietary practices
Gather 24-hour diet recall
Suggest an addition of 300 healthy calories per day
Encourage daily prenatal vitamin with 400 g folic acid
Suggest 6–8 glasses of water daily
Encourage to follow food pyramid in daily choices
ANTEPARTUM
These symbols show fats and
added sugars in foods
Vegetable group
3-5 servings
ANTEPARTUM
Fats,oils and sweets
Use sparingly
Protein group
2-3 servings
Fruit group
3-5 servings
Bread, cereal, pasta
and grain group
6-11 servings
Food Pyramid. (From U.S. Department of Agriculture and Department of Health and Human Services.)
32
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Fat (naturally occurring and added)
Sugars (added)
Dairy group
2-3 servings
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33
Weight Gain in Pregnancy
■ Recommended weight gain depends on prepregnancy
weight/BMI
Prepregnant Weight
Normal
Overweight
Underweight
Recommended Weight Gain
25–35 pounds
15–25 pounds
28–40 pounds
■ Assess and document the pattern of weight gain
Trimester
Suggested Weight Gain
1st
2nd & 3rd
1–4 pounds total
0.5–1 pound per week
Exercise in Pregnancy
■ Physical activity in pregnancy is recommended unless
contraindicated by medical complications
■ Avoid sports with potential for abdominal trauma or falls
■ Avoid overheating and supine positioning
■ STOP exercise if experiencing
■ Vaginal bleeding
■ Cramping
■ Leaking of amniotic fluid
■ Decreased fetal movement
■ Dizziness
■ Headache
■ Chest pain
■ Calf pain
■ Dyspnea
ANTEPARTUM
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Sexuality in Pregnancy
■ Sex not restricted in pregnancy unless risk factors exist for
bleeding or preterm labor
■ Discuss expected changes in sexuality
■ Change in libido
■ Body image changes
■ Braxton-Hicks contractions with orgasm
■ Comfortable positioning for intercourse
Warning Signs During Pregnancy
Patient should be instructed to notify primary health-care
provider if experiencing any of the following symptoms:
Warning Sign
Vaginal bleeding
Leakage of vaginal
fluid
Dysuria
Headache
Altered vision
Blurred vision
Flashes of light
Abdominal cramping
Severe epigastric pain
Decreased fetal
movement
Elevated temperature
Persistent vomiting
Possible Cause
Abortion
Placenta previa
Abruptio placentae
Preterm labor
Premature rupture of amniotic fluid
Incontinence of urine
Urinary tract infection
Pregnancy-induced hypertension
(PIH)
Pregnancy-induced hypertension
(PIH)
Preterm labor
Pregnancy-induced hypertension
(PIH)
Fetal demise
Infection
Hyperemesis gravidarum
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35
Nursing Care for Return Prenatal Visits
■ Measure pulse and blood pressure (BP)
■ Compare BP to initial reading (measured in the same position
at each visit)
■ Measure weight and compare to last reading
■ Note total weight gain
■ Note pattern of weight gain
■ Obtain urine specimen and test for protein and glucose
■ Measure fundal height
■ Determine fetal position
■ Perform Leopold’s Maneuver
• Palpate fetal body part in fundus (A)
• Palpate for fetal back (B)
• Palpate for presenting part (C)
• Palpate for attitude of presenting part (D)
Leopold’s Maneuver. (From Dillon PM. (2003). Nursing Health
Assessment: A Critical Thinking, Case Study Approach. Philadelphia:
F.A. Davis Company, p 739.)
ANTEPARTUM
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■ Place Doppler on maternal abdomen over fetal back to
monitor fetal heart tones (FHT)
Placement of Doppler. (LSA = left sacral anterior; LOP = left occiput
posterior; LMA = left mentum anterior; LOA = left occiput anterior; RMA
= right mentum anterior; ROA = right occiput anterior; ROP = right
occiput posterior; RSA = right sacral anterior) (From Dillon PM. (2003).
Nursing Health Assessment: A Critical Thinking, Case Study Approach.
Philadelphia: F.A. Davis Company, p 737.)
■
■
■
■
■
Record presence of fetal movement
Assess for presence of edema/deep tendon reflexes
Record symptoms since last visit
Discuss procedure for diagnostic testing
Provide patient education appropriate for gestational age
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37
Diagnostic Tests
1-hour glucose screen
Performed at 24–28 weeks
Clinical Application
Detection of gestational
diabetes
Nursing Considerations
Administer 50 g glucose load
Patient should not eat, drink,
or smoke during the test
Serum sample drawn in
1 hour
EXPECTED RESULT
140 mg/dL
Group B vaginal culture
Performed between
35–37 weeks
Clinical Application
Positive culture treated
with antibiotics in labor
to prevent newborn
transmission
Explain test to patient
Collect vaginal/rectal
specimen
EXPECTED RESULT
Negative
Fetal fibronectin (fFN)
Performed between 22
and 35 weeks in women
at high risk for preterm
labor
Clinical Application
Negative predictive value
for preterm labor
NO intercourse 24 hours
prior to exam
Cervical/posterior fornix
specimen
Antibody screen
Performed at 28 weeks in
Rh negative women
Administer Rh (D antigen)
immune globulin at 28
weeks to prevent antibody
formation if Rh negative
and antibody screen
negative
EXPECTED RESULT
Negative
Clinical Application
Detects presence of positive
antibodies in serum of Rh
negative women
ANTEPARTUM
EXPECTED RESULT
Negative
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Education in the Second and Third Trimester
■ Teach patient to count fetal movement and report change in
fetal movement pattern to primary health-care provider
immediately (See bulleted information under “Teach patient
to count fetal movements” on page 50)
■ Discuss fetal growth and development
■ Demonstrate palpating for contractions
■ Discuss symptoms of preterm labor
■ Lower backache
■ Increased vaginal discharge
■ Bloody show
■ Leaking amniotic fluid
■ Contractions
■ Pelvic pressure
■ Differentiate between true and false labor
True Labor
Cervix dilates
Contractions increase
in intensity and
frequency
Leaking amniotic fluid,
bloody show
False Labor
Cervix unchanged
Contractions irregular and
decrease with change of
position/activity
No evidence of change in
vaginal discharge
■
■
■
■
■
Encourage childbirth preparation class
Discuss options for pain control in labor
Cesarean preparation class, if indicated
Epidural anesthesia class, if indicated
Explore preparing for the newborn
■ Breastfeeding
■ Circumcision
■ Choosing a pediatrician
■ Car seat safety
■ Discuss the discomforts associated with late pregnancy and
teach reportable symptoms (in red)
38
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39
Discomfort
Changes in
pigmentation
Linea nigra
(pigmented line
from umbilicus
to pubic bone)
Chloasma (deeper
facial pigment)
Striae (stretch marks)
Round ligament
pain (occasional,
sharp lower
abdominal pain)
Braxton-Hicks
contractions
(false labor
contractions)
Ankle edema
Varicose veins
Faintness
Patient Education
Related to hormone changes in pregnancy;
fade after pregnancy
Moisturizers decrease itching, but will not
prevent striae
Report body rashes
Related to round ligament stretching as
uterus grows
Change positions slowly
Encourage good body mechanics
Report abdominal cramping, constant pain,
or bleeding
Instruct patient how to palpate contractions
Labor should occur after 38 weeks gestation
Teach patient to differentiate between true
and false labor
Report signs of preterm labor
Related to decreased venous return due to
pressure of the gravid uterus
Rest in lateral recumbent position
Elevate legs when sitting
Continue with 6–8 glasses water daily
Report generalized edema
Caused by increased venous stasis related
to pressure from the gravid uterus
Wear pregnancy support hose
Avoid lengthy standing
Change positions frequently
Report pain, redness, localized heat to legs
Related to hemodynamic changes
Avoid sudden position change
Avoid long periods without eating
Avoid lying supine
Report loss of consciousness
(Continued text on following page)
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Discomfort
Patient Education
Heartburn
Related to increased pressure on
abdominal organs and sphincter
relaxation
Encourage small, frequent meals
Avoid spicy foods
Sit up after meals
Report persistent symptoms
Backache
Related to shift in posture due to gravid
uterus
Encourage low-heeled shoes
Avoid standing for long periods
Teach pelvic tilt exercises
Report constant or rhythmic backache
Shortness of breath
Related to upward diaphragmatic
pressure exerted by the gravid uterus
Allow more time for strenuous activities
Eat small, frequent meals
Lightening will lessen symptoms
Report dyspnea with rest
Insomnia
Related to fetal movement, nocturia
Teach relaxation techniques
Encourage side-lying with pillow support
Warm milk/shower before sleep
Leg cramps
Related to uterine pressure on the pelvic
nerves or calcium imbalance
Review daily calcium intake
Teach signs of deep vein thrombosis
Report pain, redness, localized heat
Constipation
Hemorrhoids
Related to decreased gastric motility; iron
supplement may worsen constipation
Increase dietary fiber and water intake
Encourage exercise
Discourage enemas and laxatives
Report painful or bleeding hemorrhoids
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41
Pregnancy Complications
Vaginal Bleeding (before 20 weeks’ gestation)
May be related to spontaneous abortion, ectopic pregnancy, or
gestational trophoblastic disease
Spontaneous Abortion
Loss of pregnancy before viability
■ Clinical Findings
■ Vaginal spotting (may pass clots)
■ Abdominal cramping
■ Cervical changes
■ Fetal heartbeat may be present or absent
Ectopic Pregnancy
Products of conception implant outside the uterus
■ Clinical Findings
■ Vaginal spotting
■ hCG lower than expected for dates
■ Lower abdominal pain
■ Ultrasound findings: absence of intrauterine gestational sac
■ If rupture occurs:
• Positive Cullen’s sign
(periumbilical bluish hue)
• Shoulder pain
• Signs of shock
Gestational Trophoblastic Disease
Abnormal proliferation of trophoblastic cells without viable fetus
■ Clinical Findings
■ Vaginal spotting (dark brown)
■ Fundal height greater than expected for dates
■ hCG greater than expected for dates
■ Excessive nausea and vomiting
■ Absence of fetal heart tones
■ Ultrasound findings: Snowflake-like clusters,
absence of fetus
ANTEPARTUM
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■ Nursing Care (vaginal bleeding/early pregnancy)
■ Monitor amount of bleeding
■ Assess vital signs
■ Observe for signs of shock
■ Auscultate for fetal heart tones (FHTs)
■ Collect passed tissue/clots
■ Monitor patient comfort
■ Check blood type and Rh factor
■ Administer Rh(D) immunoglobulin if indicated
■ Initiate IV fluids as ordered
■ Report lab/ultrasound findings
■ Attend to patient’s emotional needs
Vaginal Bleeding (after 20 weeks’ gestation)
May be related to placenta previa or abruptio placentae
Placenta Previa
Low-lying position of placenta in the uterus that partially or
completely covers the cervical os
■ Clinical Findings
■ Painless bright red vaginal bleeding
■ Bleeding may be reported after intercourse
■ Uterine tone soft upon palpation
■ Interventions dependent on amount of bleeding and
labor status
■ If partial placenta previa is noted in early gestation, repeat
ultrasound later in pregnancy (may demonstrate absence
of previa as uterus grows)
■ If labor active and os is covered, cesarean birth necessary
■ If bleeding controlled and labor absent, conservative
management
• Patient Teaching (Conservative Management)
– No tampon use
– No sexual intercourse
– Monitor and report bleeding
– Patient instructed to report placenta placement when
admitted to hospital
– Cesarean preparation class
– Count fetal movements
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43
Internal os
Blood
External os
A
Membranes
Internal os
Blood
External os
B
Membranes
Internal os
Blood
External os
C
Placenta previa.
ANTEPARTUM
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Abrupto Placentae
■ Clinical Findings
■ Abdominal pain (sudden onset, intense and localized)
■ Fundus firm, boardlike, with little relaxation
■ Vaginal bleeding
■ Bleeding may be concealed within the uterine cavity
■ Fetal heart tones may be nonreassuring
■ Nursing Care (vaginal bleeding/late pregnancy)
■ Monitor amount of bleeding
■ Check vital signs
■ Observe for signs of shock
■ Evaluate fetal heart tones
■ Palpate uterine tone
■ Apply electronic fetal monitor (EFM)
■ REPORT alterations in fetal heart rate pattern
■ REPORT hypertonic contractions with poor resting tone
■ Do not attempt vaginal exam until placenta
placement verified
■ Initiate IV fluids
■ Report laboratory and ultrasound findings
■ Prepare staff for possible cesarean birth
■ Attend to patient’s emotional needs
Hyperemesis Gravidarum
Intractable vomiting in pregnancy with resultant weight loss and
dehydration
■ Nursing Care
■ Assess vital signs
■ Observe for signs of dehydration
■ Review electrolytes
■ Access IV site as ordered
■ Record fetal heart tones
■ Record intake and output
■ Record daily weight
■ Check urine for ketones
■ Administer antiemetics as ordered
44
Copyright © 2006 by F. A. Davis.
Premature separation of the placenta; may be partial or complete
Partial separation
(concealed hemorrhage)
Partial separation
(apparent hemorrhage)
Abruptio placentae.
Complete separation
(concealed hemorrhage)
ANTEPARTUM
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Abruptio Placentae
02Holloway (F)-02
ANTEPARTUM
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Preterm Labor
Onset of regular labor before the 37th completed week of
gestation
■ Clinical Findings
■ Rhythmic lower abdominal cramping
■ Complaints of backache
■ Increased vaginal discharge
■ Downward pelvic pressure
■ Leaking of amniotic fluid
■ Vaginal spotting
■ Cervical effacement/dilation
■ Shortening cervical length
■ Nursing Care
■ Determine gestational age
■ Assess uterine tone
■ Auscultate fetal heart tones and apply EFM
■ Obtain vaginal/urine cultures
■ Assess for leaking amniotic fluid
• Ferning—Microscopically, amniotic fluid will resemble the
leaves of a fern plant
• Nitrazine paper—Due to the alkaline nature of amniotic
fluid, the nitrazine paper will change from yellow to blue
■ Perform vaginal exam to determine dilation and effacement
of the cervix
■ Position side-lying
■ Initiate IV fluids as ordered
■ Administer corticosteroid to mother
• Accelerates maturity of fetal lungs
• Most benefit 24 hours after administered
■ Initiate tocolytic therapy
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47
Tocolytic Medication
Magnesium Sulfate
ANTIDOTE: Calcium
gluconate at bedside
β-adrenergic agonist
terbutaline
ritodrine
Prostaglandin antagonist
indomethacin
Calcium channel blockers
nifedipine
Nursing Precautions (Closely
monitor maternal and fetal
tolerance to medication)
■ Monitor for respiratory
depression
■ Assess deep tendon reflexes
■ Watch level of consciousness
■ Monitor intake and output
■ Assess fetal heart tones
■ Monitor for contractions
■ Auscultate lungs
■ Report magnesium sulfate levels
■ Monitor for hypotension
■ Assess for tachycardia
■ Assess patient for tremors
■ Assess for pulmonary edema
■ Screen glucose/potassium
■ Assess for cardiac arrhythmias
and chest pain
■ Monitor fetal heart tones
■ Monitor contractions
■ May lead to premature closure
of ductus arteriosus
■ Monitor for hypotension
■ Assess for tachycardia
Preeclampsia
Hypertensive disorder of pregnancy with multisystem involvement
■ Clinical Findings
■ Blurred or altered vision
■ Epigastric pain
■ Headache
■ Edema
■ Proteinuria
■ Hyperreflexia
■ Hypertension
ANTEPARTUM
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■ Nursing Care
■ Closely monitor vital signs
■ Assess deep tendon reflexes
■ Dipstick urine for protein
■ Record presence of edema
■ Palpate tone of fundus
■ Auscultate fetal heart rate and apply EFM
■ Monitor patient comfort
■ Collect 24-hour urine
■ Place patient in side-lying position
■ Keep environment quiet and dim
■ Institute seizure precautions
• Side rails up and padded
• Bed in low position
• Suction equipment available at bedside
• Oxygen available at bedside
■ Initiate IV fluids as ordered
■ Monitor intake and output
■ Initiate medications as ordered
Drug Therapy
Magnesium sulfate
Anti-hypertensives
Nursing Precautions
See precautions listed under preterm
labor for magnesium sulfate
Administer slowly
Closely monitor for hypotension
Eclampsia
■ Clinical Findings
■ Worsening of symptoms of preeclampsia
■ Seizure activity
HELLP Syndrome
■ Clinical Findings
■ Worsening symptoms of preeclampsia
■ Malaise
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49
■ Epigastric pain
■ Nausea/vomiting
■ Laboratory findings:
Hemolysis
Elevated Liver enzymes
Low Platelets
Gestational Diabetes
Glucose intolerance that is first recognized in pregnancy
■ Clinical Findings
■ Polyuria
■ Polydipsia
■ Polyphagia
■ Fatigue
■ Blurred vision
■ Glucosuria
■ Recurrent yeast infections
■ Slow healing wounds
■ Abnormal glucose results
• 1-hour glucose 140 mg/dL
• Abnormal 3-hour glucose tolerance test: 2 out of 4 values
elevated
FBS
1-hour
2-hour
3-hour
95mg/dL
180mg/dL
155mg/dL
140mg/dL
■ Outpatient Management
■ Dietician consult for ADA diet instructions
■ Discuss pathophysiology of gestational diabetes
with patient
■ Demonstrate home glucose monitoring
■ Review range for glycemic control
■ Demonstrate logging of glucose results
■ Discuss role of exercise in glycemic control
■ Demonstrate urine ketone testing
ANTEPARTUM
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■ Demonstrate insulin administration
■ Teach patient to count fetal movements
• Find comfortable position in quiet place and concentrate
on fetal movement
• Document time of first fetal movement and time required
for 10 movements (should not take more than 2 hours)
• If pattern of movement decreased, REPORT immediately
Fetal Surveillance in Pregnancy
Nonstress Test (NST)
■ Procedure used to monitor fetal response to movement; FHR
acceleration with fetal movement is reassuring and a sign of
fetal well being
■ Place patient in a Semi-Fowler’s or side-lying position
■ Record vital signs and apply electronic fetal monitor
■ Record baseline fetal heart rate and monitor FHR pattern for
20–30 minutes
■ Patient marks paper with each perceived fetal movement
■ NST may take longer with absence of accelerations; fetal
movement may be stimulated vibroacoustically
■ Report findings to primary health-care provider
EXPECTED FINDINGS: REACTIVE
Two accelerations of FHR within 20 minutes that are at least 15
BPM above the baseline rate and last for a minimum of 15
seconds each
Contraction Stress Test (CST)
Also called Oxytocin Challenge Test (OCT)
■ Procedure used to determine fetal tolerance to the stress of
uterine contractions
■ Calculate gestational age (should not be performed on
preterm patients; test stimulates contractions)
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51
■
■
■
■
Place patient in side-lying position
Record vital signs
Apply EFM and record baseline fetal heart rate for 20 minutes
Stimulate uterine contractions until three contractions occur
within 10 minutes lasting 40 seconds each
■ Contractions can be stimulated with
■ Nipple stimulation or
■ IV Oxytocin per hospital protocol
■ Document FHR response to contractions
EXPECTED FINDING: NEGATIVE
Three contractions that last at least 40 seconds within 10
minutes without the presence of late or significant variable
decelerations
Biophysical Profile (BPP)
■ Ultrasound exam observing four specific fetal criteria
■ Nonstress test included as a fifth parameter
■ Scoring of Biophysical Profile (BPP)
Parameter
Measured
Fetal tone
Fetal breathing
Gross fetal movement
Amniotic fluid volume
FHR reactivity per NST
Expected Findings
(within 30 minutes)
Active flexion/extension
One or more episodes lasting
30 seconds
Three or more discrete
movements
Single vertical pocket 2 cm
Reactive
EXPECTED FINDING: NEGATIVE
BPP Score of at least 6/8 if NST omitted
BPP Score of at least 8/10 if NST included
ANTEPARTUM
Score
2
2
2
2
2
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INTRAPARTUM
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Intrapartum
■ Patients present to labor and delivery for medical procedures,
triage, and birth
■ Upon admission to labor and delivery, the nurse should:
■ Determine reason for admission
■ Gather patient history
■ Review prenatal health record
■ Perform a physical exam
Prenatal History
■
■
■
■
■
■
■
■
■
Estimated date of delivery
Current gestational age
Complications in pregnancy
Results of laboratory tests and ultrasounds
Medications used in pregnancy
Presence of vaginal discharge or bleeding
Amniotic fluid status
Presence of fetal movement
Onset and pattern of contractions
Obstetrical History
Type of births
■ Vaginal
■ Instrumentation
■ Episiotomy
■ Length of labor
■ Cesarean
■ Reason for cesarean
■ Document type of incision
• Low-transverse
• Classical
■ Complications of birth
■ Neonatal outcomes
Medical History
■
■
■
■
Chronic health problems
Current medications
Time and description of last oral intake
Allergies to food/medicine
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53
Surgical History
■ Complications with anesthesia
■ Date/reason for surgery
Perform a Physical Exam
■
■
■
■
■
■
■
■
■
■
Assess maternal vital signs
Collect urine specimen for protein and glucose
Assess for presence of edema
Assess deep tendon reflexes
Perform Leopold’s maneuver to determine fetal position
Assess fetal heart rate (FHR)
Measure fundal height
Determine the frequency, duration, and intensity of contractions
Determine the stage and phase of labor
Assess cervical changes
■ Dilation (0 to 10 cm)
■ Effacement (0–100%)
■ Station (Level of presenting fetal part in relation to the ischial
spines of the maternal pelvis)
Iliac
crest
Iliac
crest
–5
–4
–3
–2
–1
0
1
2
3
4
5
Ischial
spine
Ischial
tuberosity
Perineum
Station
INTRAPARTUM
Ischial
spine
Ischial
tuberosity
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INTRAPARTUM
■ Note presence, color, and amount of bloody show
■ Check status of amniotic membranes
■ Intact
■ Bulging
■ Ruptured (note color, amount, and odor)
Nursing Responsibility with Fetal Monitoring
■ Position patient to avoid supine hypotension
■ Assess FHR and interpret findings
■ Compare FHR to maternal pulse to ensure monitoring of fetal heart
and not maternal rate
■ Implement nursing interventions for nonreassuring patterns of FHR
■ Evaluate effectiveness of nursing interventions for nonreassuring
patterns
■ Update primary health-care provider with FHR status
■ Document findings and interventions
■ Assessment of the FHR may be intermittent or continuous
Intermittent Auscultation
■ Auscultate fetal heart tones (FHT) over fetal back with Doppler
or fetoscope
Fetoscope. (From Dillon PM.
(2003). Nursing Health
Assessment: A Critical
Thinking, Case Study
Approach. Philadelphia:
F.A. Davis, p. 737.)
■ Count FHR between, during, and immediately following a
contraction
■ Note both rate and rhythm of FHR
■ Frequency of auscultation based on:
■ Phase/stage of labor
■ Hospital protocol
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55
■ Risk status
■ Labor interventions
■ Physician orders
Stage/Phase of Labor
Stage
Stage
Stage
Stage
Frequency of FHR Monitoring
1: Latent phase
1: Active phase
1: Transition
2
Every
Every
Every
Every
30–60 minutes
15–30 minutes
5–15 minutes
5–15 minutes
Continuous Fetal Monitoring
Monitored with external or internal fetal monitoring
External Fetal Monitoring (EFM)
■
■
■
■
■
Encourage patient to void before applying EFM
Test internal circuitry of EFM
Place ultrasound transducer over fetal back
Place toco transducer over uterine fundus
Monitor for 20–30 minutes on admission
Ultrasound
transducer
Toco transducer
(FHR)
(uterine contractions)
External fetal monitor
INTRAPARTUM
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INTRAPARTUM
Internal Fetal Monitoring
■ Indicated when EFM not providing adequate FHR or contraction
tracing
■ May be implemented only after amniotic sac is ruptured
■ FHR measured by spiral electrode attached to presenting part
■ Uterine tone measured by intrauterine pressure catheter (IUPC)
■ Resting tone of uterus averages 5–15 mmHG
■ Contraction tone of uterus averages 50–85 mmHG
Scalp
electrode
Catheter
Internal fetal monitor
Evaluating the Baseline Fetal Heart Rate
■
■
■
■
■
Normal baseline FHR is 110–160 BPM
Evaluated between contractions over 10 minutes
Documented as a range
Does not include accelerations or decelerations
Influences on the fetal heart rate
■ Central nervous system
Fetal sleep ↓ variability of FHR
Fetal movement ↑ variability of FHR
■ Autonomic nervous system
Sympathetic branch (↑ FHR)
Parasympathtic branch (↓ FHR)
■ Baroreceptors respond to ↓ blood pressure with subsequent
↓ FHR
■ Chemorecptors sense ↓ oxygen and ↑ FHR
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INTRAPARTUM
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Normal fetal heart rate. (Top: fetal heart rate; bottom: contractions.)
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INTRAPARTUM
Changes to Baseline Fetal Heart Rate
■ TACHYCARDIA
■ FHR greater than 160 BPM for 10 minutes
■ Possible cause:
• Infection/hyperthermia
• Fetal hypoxia
• Maternal medications (ex. terbutaline, albuterol)
■ BRADYCARDIA
■ FHR less than 110 BPM for 10 minutes
■ Possible cause:
• Vagal stimulation
• Hypoxia
• Anesthetic agents
■ VARIABILITY
■ Fluctuations in FHR over time
■ Important indicator of fetal well-being
■ Sensitive to hypoxia and changes in Ph
■ Short-term variability (STV)
• Beat-to-beat changes in FHR
• Documented as present or absent
• Most accurate with internal FHR monitoring
■ Long-term variability (LTV)
• Pattern of fluctuations in FHR baseline
(Expected pattern highlighted in blue)
Long-Term Variability
Absent (0–2 BPM)
Minimal (3–5 BPM)
Average (6–10 BPM)
Moderate (11–25 BPM)
Marked (25 BPM)
Possible Cause
Maternal medication
Fetal sleep
Fetal hypoxia
Adequate fetal oxygenation
Early sign of mild fetal hypoxia
Fetal stimulation
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59
Changes in Fetal Heart Rate
■ The nurse interprets changes to baseline FHR as reassuring
or nonreassuring
■ The nurse must act on nonreassuring FHR patterns
■ ACCELERATIONS
■ Sudden increase of fetal heart rate over baseline
■ Indication of fetal well-being
■ Reassuring pattern
■ Possible cause: Fetal movement/stimulation
Acceleration. (Top: fetal heart rate; bottom: contractions.)
■ DECELERATIONS (Early, Late, Variable)
■ EARLY DECELERATION
• Decrease in FHR occurring with contractions
• Onset occurs before the contraction peak
• Recovery to baseline rate occurs by contraction end
• Commonly seen in active phase of first stage of labor
• Mirrors the contraction
• Usually benign finding
• Continue to monitor FHR pattern for nonreassuring
patterns
• Possible cause: Fetal head compression
INTRAPARTUM
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INTRAPARTUM
Early deceleration. (Top: fetal heart rate; bottom: contractions.)
■ LATE DECELERATIONS
• Decrease in FHR occurring with contractions
• Onset with or after the peak of contraction
• Recovery to baseline rate occurs after contraction ends
• Repetitive pattern
• Nonreassuring requiring intervention
Late deceleration. (Top: fetal heart rate; bottom: contractions.)
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• Etiology: decreased uteroplacental blood flow/oxygen
delivery related to
– Maternal supine hypotension
– Hypertension
– Hyperstimulation of uterus
– Diabetes
– Preeclampsia
– Anemia
– Chronic maternal disease
■ VARIABLE DECELERATIONS
• Decrease in FHR occurring without regard to contractions
• Can range from mild to severe
• May be persistent or occasional
• Shaped like a “V” or “W”
• Onset variable
• Nonreassuring variable decelerations
– Repetitive and/or deep decrease in FHR
– Associated with minimal variability
– Prolonged with slow return to baseline FHR
• Possible causes:
– Cord prolapse
– Umbilical cord compression
• Intervention: AMNIOINFUSION may be performed to try to
relieve cord compression
– Infusion of warmed normal saline into uterus via sterile
catheter
– Monitor FHR, contraction status, and maternal temperature
– Verify that fluid is exiting uterus
Variable deceleration. (Top: fetal heart rate; bottom: contractions.)
INTRAPARTUM
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INTRAPARTUM
Nursing Interventions for Nonreassuring FHR Patterns
■ Turn patient to side-lying position
■ Shifts weight of gravid uterus off the inferior vena cava
■ Allows for improved uteroplacental blood flow
■ O2 per mask at 8–10 L/min
■ Improve oxygen delivery to fetus
■ Discontinue IV Oxytocin
■ Decreases uterine contractions, thus improving
uteroplacental blood flow
■ Hydrate patient as indicated
■ Corrects identified maternal hypotension
■ Notify primary health-care provider
■ Document findings
■ Document baseline FHR (baseline FHR should be between
110 and 160 BPM)
■ Describe variability
■ Note changes in FHR in relation to contractions
■ Document nursing interventions, effectiveness of
interventions and notification of primary health-care
provider
Monitoring Contractions
■ Frequency
■ Beginning of one contraction to the beginning of the next
contraction
■ Documented as range, for example, “every 2–5 minutes”
■ Duration
■ Beginning of the one contraction to the end of the same
contraction
■ Documented as a range, for example, “lasting 60–90
seconds”
■ Intensity
■ Palpate uterus both during and after contraction
■ Resting tone palpated between contractions
■ Document intensity of uterine contractions (findings
subjective unless monitored with IUPC)
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63
Intensity
Palpated by nurse
Mild
Moderate
Strong
Fundus easily indented
Requires more pressure to indent fundus
Unable to indent fundus
During contraction
Interval
between
contractions
nt
Duration of
contraction
Relaxation
Beginning of contraction
Acme
t
e
re m
Dec
Beginning of contraction
I n cr
eme
n
Before contraction
Contraction
Relaxation
Frequency of contractions
Counting contractions.
Nursing Care of the Laboring Patient
First Stage of Labor: Dilation
Divided into Three Phases: Latent, Active, Transition
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INTRAPARTUM
First Stage
Stage 1: Latent Phase
■ Power: Contractions palpate mild, every 5–10 minutes, lasting
30–45 seconds
■ Psyche: Patient is usually excited about the start of labor
■ Measuring progress in labor: Cervical dilation (0–3 cm)
■ Passageway: Encourage frequent position changes that optimize
fetal descent, rotation, and widen pelvic outlet
■ Ambulation (with intact amniotic sac)
■ Squatting
■ Hands and knees position
■ Rocking chair
■ Side-lying
■ Check bladder status and encourage patient to void every
2 hours
■ Nursing considerations
■ Monitor vital signs every 30–60 minutes
■ Fetal heart tones every 30–60 minutes
■ Hydration
• Oral fluids as ordered
• Monitor intake and output
■ Pain management
■ Pain medication usually avoided until in active labor
■ Techniques for pain management
• Hydrotherapy
– Shower
– Labor tub
• Massage
– Effluerage: light, circular stroking of gravid abdomen
– Counter-pressure to back
• Relaxation techniques
– Progressive relaxation
– Patterned breathing
– Soft music and lighting
– Distraction
Stage 1: Active Phase
■ Power: Contractions palpate moderate to strong, every
2–5 minutes lasting 40–60 seconds
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■ Psyche: Patient may have greater difficulty coping with the pain
of contractions
■ Measuring progress in labor: Cervical dilation (4–7 cm)
■ Passageway
■ Encourage frequent position changes
■ Check bladder status and encourage patient to void every
2 hours
■ Nursing considerations
■ Monitor vital signs every 30 minutes
■ Fetal heart tones every 15–30 minutes
■ Pain management
■ Continue with effective techniques used in latent phase
■ Systemic medications to decrease pain perception
• Document and report maternal and fetal response to
systemic medications
• Neonatal side effects related to both dose and timing of
administered medication
Systemic Pain Medications in Labor
Medication
Class
Drug
Action
Nursing
Considerations
Opioid
analgesics
Meperidine
Butorphanol
fentanyl
Nalbuphine
Reduce pain
perception
Side effect: nausea and
vomiting
Long-acting active metabolite,
may cause respiratory
depression (in the neonate)
Caution with women who are
opiate dependent, may cause
withdrawal
IV push dosing should be at the
beginning of a contraction to
limit transfer to fetus
Adjunct drugs
Promethazine
Hydroxyzine
Reduce nausea
Reduce anxiety
No analgesic effect
Sedatives
Promotes rest
with prolonged
latent phase
May have prolonged
depressant effect on neonate
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INTRAPARTUM
■ Epidurals in labor
• Oxygen, suction equipment, emergency medications
should be at bedside
• Document vital signs and monitor fetal heart rate prior to
procedure
• Encourage patient to void
• Administer IV bolus prior to epidural insertion (500 cc to
1000 cc of saline or lactated Ringer’s solution) to prevent
maternal hypotension
• Position and support patient during insertion of epidural
catheter
• Note maternal vital signs before and after test dose, then
every 5 minutes with administration; thereafter, monitor
vital signs and FHR per hospital protocol
• Evaluate bladder status every hour and encourage to
void; catheterize if unable to void or bladder overdistended
• Assess for level of anesthesia
• Monitor for comfort with contractions
• Monitor progress of labor
• Assist with position changes
• Report adverse effects
Hypotension
Pruritis (itching)
Pyrexia (fever)
Respiratory depression
Stage 1: Transition
■ Power: Contractions palpate strong, every 1.5–3 minutes
lasting 45–90 seconds
■ Psyche: Patient may feel a loss of control; provide encouragement to patient
■ Measuring progress in labor
Cervical dilation (8–10 cm)
Fetal descent (0/1 station)
■ Physical changes common with transition
■ Urge to push if presenting part is low
■ Nausea/vomiting
■ Trembling limbs
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■ Beads of sweat on upper lip
■ Increased bloody show
■ Passageway: Activity more restricted, however, encourage
positions that promote fetal rotation and descent
■ Squatting
■ Hands and knees position
■ Side-lying
■ Nursing considerations
■ Encourage patient to void
■ Monitor vital signs and fetal heart tones every 5–15 minutes
■ Pain management
■ Continue with effective techniques used in active phase
■ If systemic medications are given, consider amount of time
estimated until birth and potential for newborn effects
(respiratory depression)
■ Have naloxone hydrochloride (Narcan) available to reverse
effects if needed
■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion
■ 10 cm dilated until the birth of the baby
■ Power: Contractions palpate strong, every 2–3 minutes lasting
60–90 seconds
■ Psyche: Patient may be eager or afraid to push
■ Measuring progress in labor
■ Descent of fetus: from 1 station to crowning
■ Cardinal movements of labor (changes in fetal position that
facilitate birth)
• Engagement/Descent/Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
■ Passageway
■ Promote effective pushing
• Wait for urge to bear down called the “Ferguson reflex”
• Discourage prolonged breath-holding
• Encourage open glottis pushing
INTRAPARTUM
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■
■
■
■
■
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INTRAPARTUM
■ Position for pushing
• Squatting
• Side-lying
• Modified Lithotomy
Encourage patient to void
Patient may pass stool with pushing
Nursing considerations
■ Monitor vital signs every 15–30 minutes
■ Fetal heart tones every 5–15 minutes
Pain management per primary health-care provider
■ Pudendal block: Local anesthetic that blocks pudendal
nerve to numb lower vagina and perineum for vaginal
birth; useful with forcep delivery
■ Local anesthesia to perineum: Numbs perineum for
episiotomy/laceration repair
Prepare for the birth of the baby
■ Cleanse the perineum
■ Check working order of suction equipment, oxygen, radiant
warmer
■ Neonatal resuscitation equipment should be readily available for every delivery
■ Prepare delivery instruments
Note precise time of birth
Provide immediate care of the newborn
■ Assess airway and suction as needed
• Remove excess fluid from infant’s nose and mouth
(infants are obligate nose breathers)
• If meconium is noted in nose or mouth, endotracheal
intubation and suctioning must be performed immediately
■ Assess breathing effort (rate of at least 30 per minute)
• If respiratory effort is not observed, gently stimulate
infant by tapping sole of foot or stroking the back
• Positive pressure ventilate if tactile stimulation does not
result in respiratory effort
■ Assess circulation: heart rate 100 BPM
■ Temperature regulation
• Dry infant
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• Place infant under prewarmed radiant warmer with
temperature probe applied
• Remove wet towels and lay infant on warm blankets
• Keep temperature of labor room warm
• Once infant is stabilized, encourage skin-to-skin contact
with mother
■ Assign Apgar Score at 1 and 5 minutes
• Score of 10 possible; Score of at least 8 desirable
Apgar Score
Score
Heart Rate
Respiratory
Effort
Muscle
Tone
Reflex
irritability
Color
0
1
Absent
Absent
Less than 100
Limp
Some flexion of
extremities
Grimace
No response
Blue or pale
Slow, irregular
Body pink;
extremities
blue
2
Greater than 100
Good; crying
Active motion
Cough, sneeze or
vigorous cry
Completely pink
■ Assess for abnormalities that may need immediate
attention (example: neural tube defects, open lesions, or
birth injuries)
■ Examine umbilical cord and count number of vessels: 2
arteries and 1 vein; place plastic clamp on cord
■ Identification
• Fingerprint mother and footprint newborn
• Apply identification bands to both mother and newborn
before leaving birthing room
■ Medications
• Administer eye prophylaxis; ophthalmic antibiotic
ointment (based on hospital protocol) to prevent
chlamydial or gonococcal eye infection
• Administer vitamin K, IM to boost production of clotting
factor (needed due to sterile gut at birth)
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INTRAPARTUM
■ Weigh and measure infant (head, chest, and abdominal
circumference as well as length)
■ Assess skin for lacerations, bruising, or edema
■ Note passage of stool/urine
Third Stage: Delivery of Placenta
■ Power: Strong uterine contractions cause the placenta to
detach from the uterine wall
■ Psyche: Patient may be exhausted; encourage bonding with
baby
■ Signs of placental separation
■ Sudden gush or trickle of blood from vagina
■ Lengthening of visible umbilical cord at introitus
■ Contraction of the uterus
■ Nursing considerations
■ Instruct patient to push when appropriate
■ Note time of placenta delivery
■ After placenta expelled:
• Monitor amount of bleeding
• Monitor vital signs
• Assess fundus
– Height
– Location
– Tone
■ Administer oxytocic medication as ordered
• Stimulates uterus to contract
• Prevents hemorrhage
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver
immediately after the birth
■ Assess level of consciousness/comfort
■ Place newborn in arm of mother, encouraging skin-to-skin
contact
■ Assist with positioning for breastfeeding and bonding
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Nursing Care with Intrapartum Procedures
Induction of Labor
■ Artificial stimulation of uterine contractions to facilitate vaginal
delivery
■ Commonly performed in postterm pregnancy
■ Prior to induction of labor the nurse should note
■ Indication for induction
■ Gestational age
■ Bishop’s score
■ Any contraindications for procedure
■ Bishop’s Score
■ Assigned by primary health-care provider prior to
induction of labor
■ Higher scores indicate increased likelihood of successful labor
induction
■ Parameters of Bishop’s score
• Degree of Dilation (1–3 points)
• Percent of Effacement (0–3 points)
• Station (0–2 points)
• Consistency of cervix (0–2 points)
• Cervical position (0–2 points)
■ Use of Oxytocin (Pitocin): Hormone that stimulates uterine
contractions to induce or augment contractions
■ Assess mother and fetus 20–30 minutes prior to oxytocin
administration
■ Prepare and clearly label solution
• 10 units of Pitocin into 500–1000 ml of isotonic IV solution
• Administer IV piggyback per electronic infusion pump
• Started at small dose and gradually increased until
contractions every 2–3 minutes (follow hospital protocol)
■ Monitor maternal-fetal tolerance to procedure
• Uterine resting tone
• Contraction frequency, duration, and intensity
• Intake and output
• Fetal heart tones (baseline, variability, changes)
• Cervical dilation and effacement
• Vital signs
• Patient comfort
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INTRAPARTUM
■ Monitor for complications of oxytocin (may become evident
as dosage increases)
• Uterine hyperstimulation (excessive frequency/duration of
contractions without uterine relaxation)
• Nonreassuring fetal heart rate patterns
• If complications become apparent:
– Change position to lateral side-lying
– Discontinue IV oxytocin
– Provide oxygen per mask at 8–10L/min
– Increase rate of nonadditive IV solution
– Call primary health-care provider
■ Cervical Ripening
■ Facilitates cervical softening, effacement, and dilation
■ Indicated when there is a medical need for induction of labor
and cervix unfavorable
■ Methods:
• Laminaria tents (mechanical cervical dilator made from
seaweed)
• Prostaglandin E1-misoprostol (Cytotec)
• Prostaglandin E2-dinoprostone (Cervidil Insert, Prepidil Gel)
■ Nursing care
• Monitor fetal heart rate and contraction status for 20–30
minutes prior to procedure
• Encourage patient to void prior to insertion
• Position side-lying position after procedure
• Monitoring maternal vital signs, contractions, and fetal
status (per hospital protocol)
• Report adverse reactions to physician
– Hyperstimulation of uterus
– Nonreassuring fetal heart tones
– Nausea, vomiting, diarrhea
• Ensure proper waiting period between cervical ripening and
Oxytocin administration
■ Amniotomy
■ Artificial rupture of amniotic sac performed by the primary
health-care provider during a vaginal exam to augment
contraction frequency and intensity
■ Nursing care
• Pad bed to absorb amniotic fluid
• Document time of amniotomy
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• Document fetal heart tones immediately following
amniotomy
• Note color and amount of amniotic fluid
• Document cervical dilation, effacement, station, and
fetal presentation
• If presenting part is not engaged, limit patient activity to
prevent cord prolapse
• Once amniotic sac is ruptured, there is potential for
infection
– Monitor maternal temperature every 1–2 hours
– Limit number of vaginal exams
Vaginal Birth After Cesarean (VBAC)
■ Women who have had a previous cesarean birth may be
candidates for vaginal birth
■ Previous cesarean uterine incision documented as lowtransverse
■ No contraindications noted to VBAC
■ Physician and surgical team readily available for emergent
cesarean birth
■ Patient and physician agree that VBAC is desirable
■ Risks of vaginal birth following cesarean must be explained,
including
■ Uterine rupture with possible loss of fetus or uterus
■ Unsuccessful trial of labor with subsequent cesarean
■ Location of previous uterine scar must be documented
Low Transverse
Low Vertical
Uterine scars.
INTRAPARTUM
Classic
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INTRAPARTUM
■ Nursing care
■ Closely monitor uterine response to labor
■ Monitor fetal response to labor
■ Initiate IV access
■ Monitor for signs of uterine rupture
• Severe abdominal pain
• Nonreassuring fetal heart rate patterns
• Cessation of uterine contractions
• Ascending station of presenting part
• Vaginal bleeding
• Signs of shock
Complications in the Intrapartum Period
Prolapsed Umbilical Cord
■ Umbilical cord slips below/wedges next to presenting part
■ May lead to fetal hypoxia due to cord compression
■ Possible cause
■ Rupture of membranes without engaged presenting part
■ Non-cephalic fetal presentation
■ Symptoms
■ Prolonged variable deceleration
■ Pulsating cord palpated upon vaginal exam
■ Visible cord at introitus
■ Nursing actions
■ Stay with patient and call for assistance
■ Apply sterile glove and hold pressure of presenting part off
umbilical cord
■ Place patient in Trendelenburg position
■ Notify physician
■ Monitor fetal heart tones
■ Place sterile saline gauze over any exposed cord
■ Prepare patient for cesarean birth
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Cesarean Birth
■ Indications for cesarean birth
■ Cephalopelvic disproportion (CPD)
■ Malpresentations
■ Placenta previa/abruption
■ Umbilical cord prolapse
■ Fetal intolerance to labor
■ Maternal medical conditions
■ Preoperative Care
■ Place signed consent on chart
■ Insert urinary catheter
■ Shave prep to the abdomen
■ Remove contact lenses, nail polish, jewelry, prosthetic
device, dentures
■ Perform preoperative teaching
■ Assist significant other to prepare for observation of
surgery
■ Administer preoperative medications
■ Continue to monitor vital signs and fetal heart rate
■ Postoperative care
■ Assess respiratory/cardiac status
■ Encourage patient to turn cough and deep breath
■ Assess level of pain and medication needs
■ Monitor intake and output
■ Assess bowel sounds
■ Assess incision
■ Monitor vaginal bleeding and provide pericare
■ Assess vital signs and level of consciousness
■ Assess extremities for circulation
■ Assist with positioning for breastfeeding and holding baby
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POSTPARTUM
Postpartum
Fourth Stage of Labor
First 1–2 hours after birth
Immediate Nursing Care
■ Assess height, location, and tone of the fundus (upper portion
of the uterus)
■ Note amount and consistency of vaginal bleeding
■ Cleanse and apply ice pack to the perineum
■ Provide clean linen under patient
■ Provide warm blanket: patients often tremble/shiver immediately after the birth
■ Assess vital signs
■ Assess level of consciousness/comfort
■ Encourage bonding of mother and infant
■ Assist with proper latch-on to initiate breastfeeding
■ Maintain IV fluids and additives as ordered
■ Oxytocic medications
• Promote uterine contractions
• Decrease amount of vaginal blood loss
Nursing Assessment of the Postpartum Patient
■ Assess every 15 minutes for the first hour
■ Assess every 30 minutes for the second hour
■ Assess every 4 hours for the first 24 hours
■ Uterine tone
■ Bleeding
■ Perineum
■ Bladder status
■ Vital signs
• Blood pressure
• Pulse
• Respiration
• Temperature every 1–4 hours
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■
■
■
■
Fluid balance
Circulation to extremities
Comfort/level of consciousness
Newborn interaction
Postpartum Education
■ Education of the postpartum family is an essential role of the
postpartum nurse
■ New skills should be discussed, demonstrated, and reinforced
■ Document education and validate knowledge through
verbalization and/or return demonstration
Postpartum Assessment and Nursing Care
Remember the acronym BUBBLE
B breasts
U uterus
B bowel
B bladder
L lochia
E episiotomy
Breast assessment
■ Consistency: soft, filling, or firm
■ Nipple type and integrity
■ Type: Inverted or everted
■ Integrity: Bleeding, cracked, intact
■ Redness
■ Comfort
■ Breast care (lactating)
■ Patient should wear a supportive bra
• Montgomery glands secrete oil to keep nipples supple;
soap should not be used on breasts
• After feedings, leave colostrum/breast milk on nipples
and expose the breasts to air
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POSTPARTUM
■ Encourage frequent nursing (8–12 feedings in 24 hours)
■ Teach positioning of infant for increased comfort
• Side-lying
• Football hold
• Cradle hold
Breastfeeding positions. (Used with permission from Ross Products
Division Abbott Laboratories Inc.)
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■ Instruct on proper latch-on
• Elicit the rooting reflex by stroking the infant’s lower lip
• As the infant’s mouth opens wide, bring the infant to the
breast, ensuring both the nipple and part of the areola
are in the infant’s mouth
• Correct latch-on: infant’s jaws will rhythmically move
with an audible swallow; mother will express comfort
• Incorrect latch-on: clicking noise as infant sucks with
nipple pain expressed by mother; break suction by
placing one finger by the infant’s mouth and relatch
Latch-on. (Used with permission from Ross Products Division Abbott
Laboratories Inc.)
■ If separated from newborn, initiate breast pump
■ Breast care (nonlactating)
■ Supportive bra, breast binder or sports bra
■ No nipple stimulation
■ Do not express breast milk
■ Ice packs/analgesics for engorgement
■ Teach breast self exam (BSE)
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TEACHING TIPS: BREASTFEEDING
Advantages to Breastfeeding
■ Cost
■ Convenience
■ Immunoglobulins, which protect the infant from infection, are
passed via breast milk
■ Decreased incidence of infant:
■ Allergies
■ Otitis media
■ Upper respiratory infections
Positioning
■ The infant’s body should face the breast, with the ear,
shoulder, and hip aligned
■ Position pillows to support the weight of the infant
■ Demonstrate positions for breastfeeding
Supply and Demand
■ The newborn should be fed on demand; prolactin release in
response to suckling will stimulate the alveolar cells of the
breast to produce the appropriate amount of milk to meet the
infant’s needs
■ The mother should initiate breastfeeding when the infant
demonstrates hunger cues:
■ Increased alertness or activity
■ Smacking of the lips
■ Suckling motion
■ Moving of the head in search of the breast
■ Continue to feed until the infant detaches spontaneously, burp
the infant, and continue feeding on the other breast
■ Start breastfeeding on the breast ended with the last feeding
■ Unless medically indicated, supplemental feeding should be
avoided
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Engorgement (Firm, tender breasts)
■ May occur on postpartum day 3–5, when the volume of breast
milk increases
■ Prevent engorgement with frequent feedings; avoid skipping
any feedings
■ Treatment for engorgement
■ Express a small amount of breast milk either manually or
with a breast pump so that the breasts will soften and the
baby can latch
■ Apply cold packs to breasts intermittently
■ Apply cleaned, cooled cabbage leaves to breasts until
warm/wilted
■ Warm shower or warm compress right before feeding
Nutrition
■ Add 500 calories over nonpregnant diet
■ Continue prenatal vitamins
■ Stay well hydrated
■ Avoid alcohol, smoking, or recreational drugs
■ Consult with pediatrician before using any over-the-counter or
prescription medication
Pumping and Storing
■ Demonstrate use of breast pump
■ Discuss appropriate storage containers
■ Write the date of expression on storage container and use
oldest milk first
■ Length of storage dependent on location
Location
Guideline
Room temperature
Refrigerator
Refrigerator freezer (with separate door)
Deep freeze
POSTPARTUM
Up to 8 hours
3–5 days
3 months
6–12 months
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POSTPARTUM
Weaning
■ Gradual weaning suggested to decrease the likelihood of
engorgement
■ Remove one feeding per week
■ If infant is less than 1 year, infant formula, instead of cow’s
milk, must be given
Breast Care
■ Breast pads inside a supportive bra will collect leaking breast
milk
■ Teach signs of mastitis
■ Unilateral breast pain, warmth and redness
■ Malaise and flu-like symptoms
■ Fever
Breastfeeding Concerns
■ Mother should report breastfeeding concerns to the primary
healthcare provider
■ Feedings that are consistently short with the infant
appearing hungry after feedings and the breasts remaining
full
■ Swallowing is inaudible once milk is established
■ The infant is not gaining the expected amount of weight
■ The infant has fewer than 6 wet diapers a day; urine is
amber-colored
■ Nipple pain or cracking is present
Community Resources
■ Lactation consultant
■ La Leche League
■ Primary health-care provider
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Uterus
■ Uterine Involution
■ Process by which the size of uterus decreases in a
predictable pattern
■ Documented in fingerbreadths above or below the
umbilicus
Postpartum Period
Immediately after
birth
12 hours
24 hours
Day 2
Day 3
Level of the Fundus
at the umbilicus
1 fingerbreadth (FB)
above the umbilicus
1 FB below the umbilicus
2 FB below the umbilicus
3 FB below the umbilicus
U Umbilicus
■ Measures that promote uterine involution
• Breastfeeding
• Voiding
• Fundal massage
• Oxytoxic medications
Fundal massage.
POSTPARTUM
Documentation
at U or U/U
1/U
U/1
U/2
U/3
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POSTPARTUM
Assess the tone, height, and location of the fundus
■ TONE of the uterus assessed while patient is supine
■ Fundus should be firmly contracted
■ If fundus is not firm, perform fundal massage
■ Support the lower uterine segment during massage to
prevent inversion of the uterus
■ If fundus is boggy (not firm) after massage:
• Check bladder status and encourage voiding
• Catheterize (as ordered) if unable to void
• Notify primary care provider
■ Assess the HEIGHT and LOCATION of the uterus in relation
to the umbilicus
• Immediately after birth, fundus is located at or just above
the umbilicus
• The fundus should be midline and not deviated to the left
or right
Uterine involution. (From Dillon PM. (2003). Nursing Health Assessment:
A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis,
p. 744.)
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TEACHING TIPS: UTERINE/VAGINAL CHANGES
The Fundus
■ The fundus lowers one fingerbreadth below the umbilicus
each day until returning to pelvis (day 10–14)
Normal Progression of Lochia
■ Lochia progresses from bright red to brown to light pink with
decreasing amount
■ If lochia returns to bright red or increases in amount, decrease
activity
■ Persistent bright red lochia or lochia with a foul odor should
be reported
■ Report saturating one pad per hour or passing golf-ball size
clots
Return of the Menstrual Cycle
■ Dependent on method of infant feeding
■ If breastfeeding, lactation amenorrhea while exclusively
breastfeeding infant (first 6 months)
■ If bottle feeding, menses usually returns 6–8 weeks
postdelivery
Sexuality
■ Sexual intercourse may be resumed after lochia ceased and
episiotomy healed; 4–6 week delay generally recommended
■ Vaginal lubrication may be diminished; use water-soluble gel
■ Female superior or side-lying position may assist in comfort
■ Discuss family planning methods
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POSTPARTUM
Bladder Status
■ Postpartum women may have difficulty voiding after birth
due to:
■ Decreased urethral sensation from pressure exerted by the
passage of the fetus
■ Side effects of local/epidural anesthesia
■ Delivery trauma to the perineum
■ Palpate for bladder distention
■ Track fluid balance: intake and output
■ Assess for periurethral edema/trauma
■ Postpartum diuresis, which occurs in response to decrease in
estrogen, helps rid the body of extracellular fluid and causes
the bladder to fill quickly
■ Starts within 12 hours of birth and continues for up to 5
days
■ Urine output may be 3,000 cc/day
■ Catheterization may be necessary if unable to void or with
urinary retention
Bowel
■
■
■
■
Auscultate for bowel sounds
Assess for abdominal distention
Assess for presence/status of hemorrhoids
Educate on prevention of constipation
■ Increased roughage in the diet
■ Increased oral intake of fluids
■ Temporary use of prescribed stool softeners
Lochia
■ Vaginal discharge after delivery called lochia
■ Blood loss with vaginal birth approximately 500 cc
■ Blood loss with cesarean birth approximately 1000 cc
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■ Assess the amount of lochia
■ Note time of last perineal pad change
■ Document amount of lochia on perineal pad (scant, small,
moderate, large)
• If weighing perineal pads, 1 gm 1 ml of blood loss
■ Assess the color of lochia
• Lochia rubra (red): day 1–3
• Lochia serosa (brownish-pink): day 4–9
• Lochia alba (yellow-white): day 10–14
■ Document number and size of blood clots
■ Turn patient to assess blood loss under buttocks
Assessment of the Perineum
Requires a direct light source and positioning of the patient in
side-lying with top leg forward
■ Assess Episiotomy or laceration
■ Redness
■ Swelling
■ Ecchymosis
■ Color, consistency of discharge
■ Approximated edges
■ Lacerations described by degree of tissue involvement
Degree
1st
2nd
3rd
4th
Definition
Vaginal mucous membrane and skin of
perineum
Subcutaneous tissue of the perineal body
Involves fibers of the external rectal
sphincter
Through rectal sphincter exposing the
lumen of the rectum
■ No enemas or rectal suppositories should be used with 3rd
and 4th degree lacerations
POSTPARTUM
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TEACHING TIPS: PERINEAL HYGIENE
Perineal Cleansing
■ Stress importance of hand washing before and after perineal
care
■ Demonstrate use of perineal cleansing bottle
■ Change perineal pads after each void
■ Keep perineal pad/underwear from touching floor
Comfort Measures
■ Apply perineal ice packs intermittently for the first 24 hours
after birth
■ Sitz baths may be ordered after 24 hours
■ Apply creams, sprays, and ointments to perineum as ordered
■ Discuss bowel habits and steps to avoid constipation
Kegel Exercises
■ Encourage patient to perform Kegel exercises throughout the
day to strengthen perineal muscle tone
■ To locate muscle, tighten perineal muscles as though stopping the flow of urine (this technique is only used to locate
the muscles, not to perform the exercise)
■ Hold contraction for several seconds, release, and repeat
10–15 times; discourage breath-holding
Emotional Response
■ Assess interaction with newborn
■ Eye contact with infant
■ Talks to infant
■ Holds infant close
■ Feeds infant
■ Assess emotional status
■ Assess for postpartum blues
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TEACHING TIPS: EMOTIONS
Postpartum Blues
■ Symptoms of postpartum blues include tearfulness, insomnia,
and moodiness
■ Postpartum blues common in the early postpartum period
■ Duration less than 2 weeks
■ Possible cause
■ Hormonal changes after birth
■ Exhaustion
■ Physical discomfort
Emotional Support
■ Encourage patient to discuss feelings
■ Encourage private time when baby naps
■ Discuss the difference between “blues” and depression;
encourage patient to report symptoms of postpartum
depression
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
Extremities
■ Assess circulation to lower extremities
■ Pedal pulse
■ Color, temperature, blanching
■ Assess for signs of deep vein thrombosis
■ Pain
■ Swelling
■ Redness
■ Increased skin temperature
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Copyright © 2006 by F. A. Davis.
TEACHING TIPS: ACTIVITY
Activity Level
■ Frequent rest periods will help with healing of body and mind
(nap when baby sleeps)
■ Do not lift anything heavier than the baby
■ Limit activities to care of newborn/self
■ Ask for assistance with housework/shopping
Vital Signs
■ Temperature
■ Slight increase in temperature in first 24 hours common
due to dehydration; encourage oral fluids
■ If temperature 100.4F call physician
■ Pulse: assess rate, rhythm, and amplitude
■ Blood pressure
■ Watch for signs of shock (↓ blood pressure and ↑ pulse)
■ Be alert for orthostatic hypotension upon rising
■ Dangle at bedside before rising
■ Respirations:
■ Note rate and depth
■ Lungs should be clear on auscultation
Level of Comfort
■ Pain location and intensity
■ Afterbirth cramps: intense contractions of the uterus that
are more intense with multiparity and occur with nursing
■ Incisional pain
■ Hemorrhoid pain
■ Postpartum diaphoresis: intense sweating that occurs in the
early postpartum period ridding the body of excess fluid
■ Effects of epidural anesthesia
■ Leg movement/strength
■ Presence of numbness and tingling
■ Assist with ambulation
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Nutrition
■ Assess dietary needs and concerns
■ Average weight loss 12 pounds at birth
Laboratory Data
■ Examine postpartum laboratory findings and compare to
prenatal levels (usually drawn at 24 hours postpartum)
■ Hemoglobin/hematocrit
■ White blood cell count
■ Platelet count
■ If mother is RH negative check Rh status of infant
Mother
Negative
Negative
Infant
Rho(D) Immune globulin (300 g)
Negative
Positive
No treatment needed
Administer within 72 hours of birth
Cesarean Birth
In addition to routine postpartum assessment, the nurse should
assess the following
■ Effects of anesthesia
■ Level of consciousness
■ Ability to hold and care for infant may be limited due to
• Comfort level
• Limitation in movement
■ Respiratory status
• Pulse oximetry
Patient Controlled Anesthesia (PCA)
■ Effectiveness
■ Number of attempts/amount given
■ Side effects
Abdominal Assessment
■ Bowel sounds
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■ Abdominal distention
■ Ability to pass flatus
■ Avoid straws and carbonated beverages
■ Incision/dressing
■ Circle drainage and mark with date and time
■ Assess incision with dressing change
• Approximation
• Redness
• Drainage
• Edema
• Hematoma
• Odor
Nutrition
■
■
■
■
Intake and output
Nausea/vomiting
Presence of bowel sounds
Progression of diet
Progression of Activity
■
■
■
■
Turn/cough/deep breathe
Dangle at side of bed
Sit up in chair
Ambulate with assist
Complications in the Postpartum Period
Hemorrhage
■ Risk factors
■ High parity
■ Overdistention of the uterus
■ Precipitous labor or prolonged labor
■ Medications (oxytocin, magnesium sulfate)
■ Etiology
■ Uterine atony (hypotonia of the uterus)
■ Retained placental fragments
■ Vaginal/cervical laceration
■ Hematoma
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■ Clinical findings
■ Perineal pad saturated in less than 1 hour
■ Continuous trickle of vaginal bleeding
■ Firm, bruised area on perineum
■ Interventions
■ Fundal massage
■ Monitor urine output
• Check bladder status
• Catheterize if needed
■ Increase mainline IV fluids
■ Closely monitor vital signs
■ Administer oxygen
■ Call primary health-care provider
• May need suturing of laceration
• May need evacuation of hematoma
• May need evacuation of placental fragments
■ Administer medications that promote uterine contraction as
ordered
■ Oxytocin
■ Methylergonovine maleate (Methergine)
• If blood pressure 140/90, hold and call primary care
provider
■ Ergonovine maleate (Ergotrate)
■ Prostaglandin F2a (Prostin/Hemabate)
Infection
■ Symptoms
■ Temperature elevation 100.4F
■ Elevated white blood cell count
■ Complaint of chills and aching
■ Malaise
■ Interventions
■ Obtain culture of discharge as ordered
■ Report abnormal laboratory findings
■ Administer antibiotic therapy as ordered
■ Consider medications contraindicated for breastfeeding
■ Monitor temperature
■ Clean and monitor site
■ Teach patient reportable signs and symptoms
POSTPARTUM
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■ Endometritis (uterine infection)
■ Contributing factors
• Operative birth
• Long labor with multiple vaginal exams
• Internal monitoring
• Premature rupture of membranes
• Manual removal of placenta
■ Clinical findings
• Subinvolution of the uterus
• Foul-smelling vaginal discharge
• Lower abdominal cramping
■ Mastitis (breast infection)
■ Contributing factors
• Alteration in nipple integrity
• Delayed emptying of breast milk
■ Clinical findings
• Unilateral breast pain, warmth and redness
• Malaise and flu-like symptoms
■ Incisional infection
■ Contributing factors
• Inadequate care of incision
• Operative delivery
• Laceration
■ Clinical findings
• Incision not well approximated
• Incision red with purulent drainage
■ Urinary tract infection
■ Contributing factors
• Catheterization of bladder
• Retention of urine in bladder
■ Clinical findings
• Dysuria
• Frequency of urination
• Flank pain
Postpartum Depression
■ Risk factors
■ History of depression or anxiety disorder
■ Prenatal depression
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■ Inadequate social or partner support
■ Large number of life stressors
■ Clinical findings
■ Symptoms extend beyond 2 weeks postpartum; may occur
3–12 months after birth
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
■ Interventions
■ Psychotherapy
■ Medications
Thrombophlebitis/Deep Vein Thrombosis
■ Risk factors
■ Varicosities
■ Advanced maternal age
■ Obesity
■ Long periods of bed rest
■ Occupation that requires long periods of standing
■ Clotting disorder
■ Etiology
■ Increased clotting factors in postpartum period
■ Infection in the vessel lining to which a clot attaches
■ Clinical findings
■ Pain with dorsiflexion
■ Affected site hot to touch
■ Swelling, redness, and pain to affected leg
■ Interventions dependent on severity of findings
■ Administer anticoagulants
■ Monitor coagulation profile
■ Compression stockings
■ Apply warm, moist heat
■ Rest
■ Observe for symptoms of pulmonary embolism
• Dyspnea
• Chest pain
• Hemoptysis
• Patient fearful
POSTPARTUM
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POSTPARTUM
TEACHING TIPS: POSTPARTUM COMPLICATIONS
Teach the patient to report the following signs and symptoms to
the primary health-care provider.
Signs of infection
■ Elevated temperature
■ Localized redness or pain to either breast
■ Persistent abdominal tenderness
■ Persistent pain to perineum
■ Burning, frequency, or urgency of urination
■ Foul odor to lochia
■ Redness, pain, or discharge at incision
Sign of Uterine Subinvolution
■ Change in the character of lochia
■ Increased amount of lochia
■ Resumption of bright red color
■ Presence of clots
Signs of Thrombophlebitis/Deep Vein Thrombosis
■ Pain, increased temperature and redness to legs
Signs of Postpartum Depression
■ Extreme or unswerving sadness
■ Compulsive thoughts
■ Feelings of inadequacy
■ Inability to care for infant and/or self
■ Suicidal thoughts
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Nursery Care of the Newborn
■
■
■
■
■
Keep infant warm during all care and procedures
Assess and record daily weight
Role model back sleeping
Keep bulb syringe at bedside
Check identification bands at each encounter with parents
Physical Assessment of the Newborn
Reportable findings in red
Vital Signs
■ Axillary temperature 97.8–98.6F
■ Decreased body temperature may be a sign of sepsis
■ Auscultate apical pulse for one full minute
■ 110–160 beats per minute
■ Sustained resting heart rate below 100 or above 160
■ Respirations counted for one full minute
■ 30–60 per minute
■ Sustained resting respiratory rate below 30 or above 60
Extremities/Activity
■ Newborn posture flexed
■ Extremities equal length with full range of spontaneous
motion
■ Gluteal folds even
■ Ten fingers and 10 toes without webbing (syndactyly) or extra
digit (polydactyly)
■ Grasp reflex intact
■ REPORT
■ Poor muscle tone or asymmetry of muscle tone
■ Failure to spontaneously move all extremities or decreased
range of motion
■ Chewing type mouth movements combined with noticeable
changes in eye and/or body movements (may represent
neonatal seizure activity)
■ Unequal knee height, leg length, or asymmetrical gluteal
folds (hip dysplasia)
■ Resistance to neck flexion
POSTPARTUM
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POSTPARTUM
TEACHING TIPS: NORMAL NEWBORN BEHAVIOR
Pattern of Sleep
■ Newborns sleep in short periods for a total of 13–16 hours per
day
■ Lying the baby on the back for sleep is recommended
Communication
■ Crying is a means of communication and a late sign of hunger
■ Teach parents hunger cues
■ Teach techniques for comforting the fed newborn
■ Swaddling
■ Burping
■ Massage
■ Soft music
■ Diaper change
■ Gentle rocking
■ Encourage parents to talk, sing and hold newborn close
Skin
■ Color uniformly pink
■ Normal variations
■ Acrocyanosis (bluish hue to hands/feet)
■ Milia (plugged sebaceous glands on nose)
■ Lanugo (downy hair on arms, back, face)
■ Mongolian spot (area of increased pigmentation, resembles
bruise)
■ Telangiectases “stork bites”
■ Erythema toxicum (newborn rash)
■ REPORT
■ Cyanosis (other than in hands and feet)
■ Skin lesions, bruises, abrasions
■ Jaundice
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TEACHING TIPS: SKIN CARE AND BATHING
■ Sponge baths recommended until the umbilical cord stump has
fallen off and circumcision has healed
■ Stay with baby and hold securely at all times when bathing
■ All supplies should be within easy reach
■ No soap is needed on the face
■ The eye area can be cleansed with wet cotton balls (inner to
outer canthus)
■ Only soap recommended for newborn skin should be used
■ Dry the baby quickly to avoid chilling
■ Wash hair last to avoid heat loss
■ Encourage frequent diaper changes
■ Cleanse genital area with mild soap and water
■ Cleanse the female genitalia from front to back
■ Do not forcibly retract the foreskin of uncircumcised boys
Head
■ Head round with slight molding (cone-shaped with overriding
cranial bones) or caput succedaneum (tissue edema that crosses
suture lines)
■ Anterior and posterior fontanels (soft spots) flat
■ REPORT
■ Sunken or bulging fontanels when infant is at rest
■ Cephalhematoma, unilateral swelling of scalp tissue caused
by collection of blood between the skull and periosteum
Face
■ Face symmetrical with rest and crying
■ Eyes symmetrical in size and shape with intact red and corneal
reflex
■ Nose midline with nares patent
■ Ears aligned with outer canthus of eyes; pinna well-formed and
hearing intact
■ Oral mucosa pink and moist; tongue mobile
■ Hard and soft palate intact
■ Strong suck; able to coordinate suck and swallow
■ REPORT
■ Absence of red reflex
■ Purulent discharge of eyes immediately after birth
POSTPARTUM
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■
■
■
■
■
■
■
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POSTPARTUM
Low set ears
Lack of response to sound
Nasal flaring
Cleft lip or palate
Large, protruding tongue (possible Down syndrome)
White patches in mouth (Candidiasis)
Absent rooting, suck, or Moro reflex
Severe drooling and/or coughing or gagging
TEACHING TIPS: BOTTLE FEEDING
Types of Formula
Directions for dilution of formula on the container must be
followed exactly to ensure adequate infant health and nutrition
■ Ready-to-feed
■ Most expensive, but most convenient
■ Use without dilution
■ Opened cans can be stored in the refrigerator for 48 hours
■ Concentrated
■ Dilute with equal parts of water
■ Prepare enough bottles for the day
■ Prepared bottles can be stored in refrigerator for 48 hours
■ Powdered
■ Least expensive
■ Add water for every one scoop of powder per manufacturer’s instructions
■ Shake well to distribute powder
Formula Preparation
■ Clean off can with soap and water before opening
■ If water supply questionable, use bottled nursery water
■ Prepared bottles can be fed at room temperature; run
refrigerated bottles under warm water to bring to room
temperature
■ Avoid use of microwave for heating formula
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Bottle Preparation
■ Bottles should be washed with a brush and rinsed thoroughly;
if water supply is questionable, sterilization recommended
■ Choose nipples that allow a steady flow of formula but not so
large as to cause choking
Technique for Feeding
■ Encourage parents to hold the baby close and talk to the
infant during feedings
■ Do not prop bottles
■ On-demand feeding recommended/watch baby for hunger
cues (usually every 3–4 hours)
■ Increased alertness or activity
■ Smacking of the lips
■ Suckling motion
■ Moving of the head in search of the breast
■ Newborns generally drink about 0.5–2 ounces of formula per
feeding for the first several days of life
■ Elicit the rooting reflex to initiate feeding
■ Keep bottle tipped to ensure the nipple remains full of
formula
■ Burp every 1–2 ounces
■ The type, amount and pattern of feedings should be discussed with the pediatrician before hospital discharge
■ Formula remaining in the bottle must be discarded
Chest
■
■
■
■
■
Respirations unlabored
Chest rises and falls symmetrically
Lung sounds clear bilaterally
Clavicals intact
REPORT
■ Nasal flaring, chest retractions, or expiratory grunting
■ Asymmetrical breath sounds
■ Chest asymmetrical or circumference greater than head
circumference
■ Loud cardiac murmur with thrill
POSTPARTUM
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POSTPARTUM
Abdomen/Genitals
■
■
■
■
■
■
■
■
Abdomen round and soft without palpable masses
Three vessel umbilical cord with drying base
Bowel sounds present
First void within 24 hours (may be rust-stained from uric acid
crystals)
Meconium stool passed within 24 hours
Female genitalia
■ Labia majora covers minora
■ May have mucoid vaginal discharge or pseudomenses
Male genitalia
■ Urinary meatus at tip of penis
■ Testes descended
REPORT
■ Drainage of urine or feces from umbilicus
■ Liver more than 3 cm below right costal margin
■ Abdomen markedly distended or flat
■ Palpable abdominal mass
■ Visible peristaltic waves
■ Poor feeding or excessive spitting or vomiting
■ Failure to urinate or pass meconium within 24 hours
■ Hypospadias or epispadias
■ Mass in scrotal or inguinal area
■ Imperforate anus
TEACHING TIPS: NEWBORN CARE
Umbilical Cord Care
■ The cord will fall off spontaneously in 10–14 days; do not tug
at cord
■ Cleanse cord insertion site at diaper changes
■ Fan fold diaper to expose cord to air
■ REPORT redness, drainage, bleeding, foul odor from cord
Circumcision
■ Site may be covered with petroleum gauze dressing; tell parents
when to remove dressing
■ Clean area with warm water for diaper change
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■ Apply petroleum jelly to head of penis to decrease friction
with diaper
■ A yellow exudate forms on the head of the penis on day 2–3;
this is part of the healing process and removal should not be
attempted
■ Reportable symptoms
■ Difficulty urinating
■ Persistent bleeding from the site
■ Pus oozing from the site
■ Redness or swelling
Back
■ Spine straight, intact, and easily flexed
■ REPORT
■ Arched back
■ Tuft of hair on spine
TEACHING TIPS: SAFETY, HEALTH MAINTENANCE
Safety
■ Discuss choking hazards and demonstrate the proper use of
the bulb syringe
■ Properly installed car seats must be consistently used with
safety straps on
■ Crib mattress should be firm and fit snugly; crib slats should
be no more than 2 3/8” apart
■ Never leave baby unattended on household furniture other
than crib
■ Test bath water and formula temperature to prevent burns
■ Shield skin from excessive sun exposure
■ Supervise pets around the baby
■ Reduce the risk of Sudden Infant Death Syndrome (SIDS)
■ Back sleeping recommended
■ Avoid pillows and stuffed toys in the crib
■ Use firm, well-fit mattress
■ No smoking around baby
■ Dress baby for comfort; do not overheat
POSTPARTUM
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POSTPARTUM
Immunizations
■ Discuss importance of immunizations for disease prevention
■ Provide current schedule of recommended childhood
immunizations
■ Provide documentation of any immunization given in the
hospital
Neonatal Genetic and Hearing Screen
■ Blood test for metabolic defects are performed on all newborns after feeding is established
■ Exact tests vary by state
■ Infants who are discharged early may need to be brought
back for newborn screen
■ Hearing screen done before hospital discharge for early
identification of hearing deficits
Reportable Symptoms
■ Parents should call the pediatrician with the following signs or
any time they are concerned with their newborn’s behavior
■ Difficulty breathing
■ Vomiting or diarrhea
■ Less than expected voids/stools
■ Yellow hue to the skin or sclera
■ Constant crying
■ Difficulty awakening baby
■ Altered temperature
■ Body rash
■ Lack of interest in eating
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Peds Basics
Common Developmental Milestones (ages are aproximate)
0–6 mo
■ Physical
■ Ht ↑ 1 in/mo
■ Doubles wt by 5–6 mo
■ Wt ↑ 1.5 lb/mo
■ HC ↑ 0.5 in/mo
■ Gross/Fine Motor
■ Rolls back to side: 3 mo
■ Holds head erect: 4 mo
■ Voluntary grasp: 5 mo
■ Rolls from front to back: 5–6 mo
■ Language
■ Coos: 1–2 mo
■ Laughs: 2–4 mo
■ Makes consonant sounds: 3–4 mo
■ Imitative sounds: 6 mo
■ Personal-Social
■ Regards a person’s face: 1 mo
■ Displays social smile and follows object 180 degrees: 2 mo
■ Recognizes familiar faces: 3 mo
■ Stranger anxiety begins: 6 mo
6–12 mo
■ Physical
■ Ht ↑ 50% of birth ht by 1 yr
■ Wt ↑ 1 lb/mo
■ Triples wt by 1 yr
■ HC ↑ by 33%
■ Chest circumference 1 in HC
■ Post fontanel closes: 2–3 mo
■ Ant. fontanel closes: 12–18 mo
■ Central incisors erupt: 5–7 mo
■ Gross/Fine Motor
■ Holds head erect: 4 mo
■ Grasps voluntarily: 5 mo
PEDS
BASICS
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PEDS
BASICS
Copyright © 2006 by F. A. Davis.
■ Begins to crawl: 7 mo
■ Sits unsupported: 8 mo
■ Pulls up to stand: 9 mo
■ Drinks from cup: 9 mo
■ Pincer grasp: 8–10 mo
■ Builds two-block tower: 12 mo
■ Walks alone or holding onto one hand: 12 mo
■ Language
■ Pronounces syllables (da-da, ma-ma) : 8 mo
■ Says 4–10 words: 12 mo
■ Personal-Social
■ Marked stranger anxiety: 8 mo
■ Emotions such as jealously: 12 mo
1–3 yr
■ Physical
■ Ht ↑ 3 in/yr
■ Wt ↑ 5 lb/yr
■ Weighs about 4 times birth wt: 2 yr
■ HC equals chest circumference: 1–2 yr
■ HC ↑ 1 in during 2 yr
■ 10–14 temporary teeth
■ Gross/Fine Motor
■ Walks without help: 15 mo
■ Walks up and down stairs placing both feet on each step:
24 mo
■ Scribbles spontaneously: 15 mo
■ Builds 3–4 block tower: 18 mo
■ Jumps with both feet: 30 mo
■ Language
■ Says 300 words: 2yr
■ Uses 2–3 word phrases and pronouns
■ Understands speech: 2 yr
■ States first and last name: 2.5 yr
■ Personal-Social
■ Separation anxiety peaks
■ Ritualism
■ Negativism
■ Independence
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107
3–6 yr
■ Physicial
■ Ht ↑ 2.5–3 in/yr
■ Wt ↑ 4–6 lb/yr
■ HC ↑ 0.5 in/yr
■ Vision is 20/20 with color vision intact: 5–6
■ Gross/Fine Motor
■ Rides tricycle: 3 yr
■ Climbs stairs using alternate feet: 3 yr
■ Stands on one foot: 3 yr
■ Broad jump: 3 yr
■ Builds 9–10 block tower: 3 yr
■ Draws a cross: 3 yr
■ Hops on one foot: 4 yr
■ Skips: 4 yr
■ Catches a ball: 4 yr
■ Walks downstairs using alternate feet: 4 yr
■ Laces shoes: 4 yr
■ Copies square: 4 yr
■ Adds three parts to stick figure: 4 yr
■ Balances on alternate feet: 5 yr
■ Ties shoelaces: 5 yr
■ Uses scissors well: 5 yr
■ Prints letters, numbers and name: 5 yr
■ Language
■ Says 900 words: 3 yr
■ Speaks 3–4 word sentences: 3 yr
■ Says 1500 words: 4 yr
■ Tells stories, sings songs: 4 yr
■ Asks “why” questions: 4 yr
■ Says over 2000 words: 5 yr
■ Knows and can name colors: 5 yr
■ Names days of week: 5 yr
■ Personal-Social
■ Shares toys with others
■ Imitates caregivers
■ Domestic role-playing
PEDS
BASICS
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PEDS
BASICS
Copyright © 2006 by F. A. Davis.
6–12 yr
■ Physical
■ Ht ↑ 2–3 in/yr
■ Wt ↑ 4.5–6.5 lb/yr
■ Secondary teeth erupt with central incisors and first molars
■ Tanner stage 2 may begin
■ Gross/Fine Motor
■ Rides bicycle
■ Roller skates
■ Run, jumps, swims
■ Cursive writing: 8 yr
■ Computer and craft skills
■ Language
■ Devlops ability to read at grade level
■ Personal-Social
■ School relationships and work important
■ Separating from family
12 to 18–21 yr
■ Physical
■ Puberty beings in girls: 8–14 yr (lasts about 3 yr)
■ Puberty begins in boys: 9–16 yr (lasts longer)
■ Ht and wt ↑ variable during puberty
■ Progressive Tanner stages of development
■ Gross/Fine Motor
■ Gross motor reaches adult levels
■ Fine motor continues to be refined
■ Language
■ Develops formal thought—includes idealism, egocentrism,
and ability to consider abstract possibilities
■ Personal-Social
■ Works through identity issues, status, and relationships
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Growth
■ Use Growth Charts from National Center for Health Statistics
(NCHS) www.cdc.gov/growthcharts, for ht, wt, wt for ht, HC,
and BMI
■ Use 5th and 95th percentiles as parameters in determining if
children are within normal limits for growth
Average Daily Caloric Requirements for Children
Age
0–1 month
2–4 months
5–60 months
5 years
Caloric Expenditure Per Day
100—110 kcal/kg/day
90—100 kcal/kg/day
70—90 kcal/kg/day
1500 kcal for first 20 kg 25 kcal for each
additional kg/day
From Hay WW, et al. (2005). Current Pediatric Diagnosis & Treatment: (17th ed.).
New York: Lange Medical Books/McGraw-Hill, p. 309.
Number and Volume of Infant Feeds
Breast Feeding: Eight to 12 feedings/24 hours during the first
6 months
Formula Feeding: Six to eight feedings/24 hours of commercially
prepared iron-fortified (3–4 ounce) for each feeding for first
month to 5 feedings/24 hours for each feeding when solid foods
introduced at 6 months
Weaning: Should be gradual, based on infant’s desire—usually
between 8 to 9 months of age.
PEDS
BASICS
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PEDS
BASICS
Copyright © 2006 by F. A. Davis.
Total Water Requirements/24 Hours
Infant 500–1300 mL; Child 6 yr 1150–2000 mL;
6 yr 2000–2700 mL
Daily Urine Output/24 Hours
0.5–2 mL/kg/hr depending on child’s age and hydration status
Infant 350–550 mL; Child 500–1000 mL;
Adolescent 700–1400 mL
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of
Pediatrics, (17th ed). Philadelphia: W.B. Saunders, p. 2415.
Average Ranges for Pediatric Vital Signs
Age
Group
Heart
Rate
Infant
Toddler
Preschooler
School-age
Adolescent
80–150
70–110
65–110
60–95
55–85
Respiratory
Rate
25–55
20–30
20–25
14–22
12–18
BP
Systolic
BP
Diastolic
65–100
90–105
95–110
100–120
110–135
45–65
55–70
60–75
60–75
65–85
Adapted from Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook
of Pediatrics (17th ed). Philadelphia: W.B. Saunders, p. 280; and National Heart,
Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the
Second Task Force on Blood Pressure Control in Children. Author, Bethesda, MD.
Rule of Thumb to Determine BP:
Normal systolic ranges: 1–7 yr age in yr 90; 8–18 yr (2 age in yr) 83
Normal diastolic ranges: 1–5 yr 56; 6–18 yr 52
110
Copyright © 2006 by F. A. Davis.
Usually breast
milk;
commercially
prepared
iron-fortified
formula
Comments Sometimes give
rice cereal
mixed with
breast milk or
formula
around 4 mo
6 mo
8–9 mo
Begin with infant
rice cereal, then
vegetables, and
fruits with meats
the last food to
introduce; start
with 1–2 tsp
Introduce one food
at a time for 3–5
days to watch
for food
allergies; do not
use honey on
young infants
because of the
association with
infant botulism;
use small spoon
to feed infant
Finger foods such
as teething
crackers or raw
fruits
Eating normal table
foods; healthy
habits—go to www.
mypramid.gov
12 mo
Watch sizes and
types of food
for possible
choking
Provide a variety of
foods that meets
child’s nutritional
needs; avoid
allergenic foods
such as nuts, egg
whites, shellfish,
strawberries, or
chocolate
PEDS
BASICS
Birth-6 mo
Types of
Foods
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PEDS
BASICS
Copyright © 2006 by F. A. Davis.
Pediatric Coma Scale
Pupils
Right
Size
Reaction
Size
Reaction
Left
Spontaneously
To Speech
To Pain
None
Obeys Commands
Best Motor
Response (use
Localizes Pain
best arm or age- Flexion Withdrawal
appropriate
Flexion Abnormal
response)
Extension
None
Best Response
Age Appropriate
Auditory/Visual
Orientation
Stimulus
Confused
Inappropriate Words
Incomprehensible Words
None
Endotracheal Tube or Trach
Eyes Open
4
3
2
0
6
5
4
3
2
1
5
4
3
2
1
T
Coma Scale Total (7 coma; 3 deep coma)
Pupil Reaction: Brisk, Sluggish, — No reaction, C Eye
closed due to swelling
Adapted from Hahn YS, et al. (1988). Head injuries in children under 36
months of age. Child Nervous System 4: 34.
112
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113
Normal Breath Sounds
■ Vesicular Breath Sounds: Soft, swishing noise heard over
entire area of lung surface except for upper scapular area
and beneath sternum; inspiration is louder, longer, and
higher pitched than expiration
■ Bronchovesicular Breath Sounds : Heard over sternum and
upper scapular regions where trachea and bronchi bifurcate;
inspiration is louder and higher pitched than vesicular breath
sounds
■ Bronchial Breath Sounds : Heard over trachea near
suprasternal notch with inspiratory phase short and expiratory
phase longer
Abnormal Breath Sounds
■ Decreased or unequal breath sounds : No or slight sound of
normal breath sounds that may indicate airway obstruction,
pneumothorax, pleural effusion, pneumonia
■ Rhonchi : Low-pitched, snoring-like, continuous sound
associated with respiratory infections
■ Crackles : Soft, high-pitched, intermittent sounds due to small
collapsed airways popping open
■ Grunting : Harsh sound on expiration due to early closure
of glottis and chest wall contraction, which causes increased
expiratory airway pressure to prevent airway collapse
■ Stridor : High-pitched, crowing sound on inspiration due to
upper airway obstruction associated with croup or foreign
body aspiration; low-pitched, muffled sound associated with
epiglottis
■ Wheezing : Musical, more continuous inspiratory or
expiratory sounds due to lower airway obstruction with
bilateral wheezing indicative of asthma or bronchiolitis and
unilateral wheezing suggestive of foreign body aspiration
PEDS
BASICS
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PEDS
BASICS
Copyright © 2006 by F. A. Davis.
Endotracheal Tube Suctioning
■ Select size of suction catheter based on size of child (infant
5–8 F, child 8–10 F, older child 12–14 F)
■ Select vacuum pressure between 60 and 100 mm Hg for
infants and young children
■ Use oxygen before suctioning and after suctioning
■ Insert catheter no greater than 0.5 cm beyond tip of artificial
airway
■ Limit suction to less than 5 seconds
Pulse Oximetry
Normal ranges: 95%-100%
Mild hypoxia: 91%-94%
Moderate hypoxia: 86%-90%
Severe hypoxia: 86%
Watch for false lows associated with nonsecure connection
(movement of child’s foot or hand), cold
extremities/hypothermia, and hypovolemia. Watch for false highs
associated with carbon monoxide poisoning and anemia.
Cardiac/Apnea Monitors
Electrode placement for ECG monitoring:
White color for right side of chest
Green (or red) color for ground
Black color for left side of chest
Electrode placement for apnea monitoring:
Two electrodes placed two fingerbreadths below nipple on
midaxillary line of each side
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115
Cardiac/Apnea Monitors (Cont.)
Electrode Placement for Standard Chest
Electrographic Monitoring
Electrodes with attached wires are
often color coded:
White for right
Green (or red) for ground
Black for left
Apnea (if indicated)
Electrode placement for both ECG and apnea.
PEDS
BASICS
Page 115
Separation Anxiety
Loss of Control
Fears
Infant
Develops ~6 mo and lasts until
30 mo with reactions of
crying or agitation
Disruption of care
from primary
caregiver and
normal routines
Toddler
Exhibits reactions such as
agitation, temper tantrums,
uncooperativeness and
clinging to parents;
separation anxiety peaks
12–15 mo
Disruption from
normal routine
and rituals as
well as care
from parents
Preschooler
Fewer reactions but more
somatic signs such as
vomiting, urinary frequency
or incontinence, diarrhea,
dizziness; still may become
withdrawn or aggressive
Perceived
disruption in the
loss of their
own power and
altered family
roles
Strangers and strange
places, loud noises,
sudden movements,
loss of physical and
emotional support
Strangers, dark, being
alone, physical
contact/interventions
from strangers,
strange or unknown
equipment and
places
Mutilation, the
unknown, any
intrusive procedures
(Continued text on following page)
116
Copyright © 2006 by F. A. Davis.
PEDS
BASICS
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117
Separation Anxiety
Loss of Control
Fears
School Age
Anxious behaviors as well as
loneliness, boredom,
isolation or depression;
knows that parents may need
to leave and will be back but
may show aggression and
irritability toward family
Enforced
dependency and
altered family
roles
Bodily injury, pain,
inability to stay in
control, lack of
control over modesty, school and peer
concerns, death
Adolescent
Anxiety related to peers and
school life with behaviors
such as withdrawal,
loneliness, or boredom
Enforced
dependency and
possible
identity/role
changes
Loss of peer
interactions and
relationships, body
disfigurement,
rejection by others,
loss of physical
abilities, death
Eight Questions to Ask About Pain:
1. Are you having pain?
2. If yes, what does the pain feel like? (burning,
aching, pinching, stabbing?)
3. When did the pain start? (Did anything happen
to start the pain?)
4. Where is the pain? (Point to where the pain is.)
5. How long have you been having pain?
6. How often does it occur?
7. Does anything make it worse—or
better?
8. Has it changed what you do?
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Children’s Responses to Illness and Hospitalization (Continued)
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Copyright © 2006 by F. A. Davis.
Developmental Differences in Children Related to Pain
Age
Infants
Young child
Older child
Adolescent
Comments
Preverbal. Signs of possible pain: diffuse body
movement, high-pitched cry, tearing, stiff
posture, fisting, and lack of play; obvious
sign is facial expression with brows lowered
and drawn together, eyes tightly closed, and
mouth open
Limited vocabularies still make it difficult to
express pain; may use words such as
“owie;” can sometimes describe pain but not
the intensity. Signs of possible pain:
regression with arms and legs thrashing or
withdrawal such as clinging to parent or
significant other, loud crying or screaming
Use pain scale for this group; may have
difficulty in distinguishing between types of
pain such as “sharp” or “dull;” may act
“tough” even when in pain; may show fewer
overt pain behaviors. Signs of possible pain:
muscular rigidity such as clenched fists,
gritted teeth, body stiffness, closed eyes,
wrinkled forehead or lying in fetal position
Use pain scale for this group; may be stoic
because of fear of being labeled so may be
quiet and withdrawn. Signs of possible pain:
fist-clenching, clenched teeth, rapid
breathing, and guarding affected body part,
lack of interest and decreased ability to
concentrate
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119
Nursing Interventions Related
To Pain Management
■ Distraction—useful for mild pain relief (example: tell child to
say “Oh” when giving an injection or blow bubbles when
performing a procedure)
■ Guided imagery—aid the child in creating a pleasurable
mental image during the painful situation
■ Thought stopping—stop the painful thought with a positive
thought
■ Soothing music or aromatherapy–use to calm emotions and
state of mind
■ Thermotherapy–apply warm and cold to painful areas to
promote circulation or reduce edema with limited numbing
effect
■ Gentle massage–relax or focus child away from pain toward
more gentle soothing touch
■ Sucrose “Sweet” Nipple—calm young infants by allowing
them to suck on nipple dipped in sucrose solution—effective
method in reducing pain during procedure
■ Provide ordered pharmacological interventions such as
topical anesthetic creams, PO/IV/IM analgesia, patientcontrolled analgesia (PCA), conscious sedation, or epidural
analgesia
Numerical Scale Pain Assesment Tool
None 0—1—2—3—4—5—6—7—8—9—10 Worst Pain
(Scale of 0–10 to describe pain) Explain to older child: “0 means
you feel no pain and 10 means you feel the worst pain possible.”
Ask the child to choose number that best describes his or her
own pain.
PEDS
BASICS
Rating:
0
Face
No particular
expression or smile
Legs
Normal position or
relaxed
Lying quietly, normal
position, moves
easily
No cry (awake or
asleep)
Activity
Cry
Consolability
Content, relaxed
1
Occasional grimace or
frown, withdrawn,
disinterested
Uneasy, restless, tense
Squirming, shifting back
and forth, tense
Moans or whimpers,
occasional complaint
Reassured by occasional
touching, hugging, or
“talking to,” distractible
2
Frequent to constant
frown, clenched jaw,
quivering chin
Kicking, or legs drawn
up
Arched back, rigid or
jerking
Crying steadily,
screams or sobs,
frequent complaints
Difficult to console or
comfort
Ages of use: 2 mo to 7 yr. Scoring range: 0 no pain, 10 worst pain.
From Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. (1997). The FLACC: A behavioral scale for scoring
postoperative pain in young children. Pediatric Nursing 23(3): 293–297.
120
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FLACC Pain Assessment Tool
Copyright © 2006 by F. A. Davis.
Infants
Toddlers
Preschoolers
Type and Purpose of Play
Safe Toys
Solitary (noninteractive but may be
1–3 mo: mobiles, music boxes,
imitative in later part of infancy)
nonbreakable mirrors, stuffed
Stimulates psychological and
animals, and rattles
sensorimotor development, offers
4–6 mo: squeezable toys, busy boxes,
diversion, means of communication
play gyms
7–9 mo: cloth textured toys, splashing
bath toys, large blocks and large balls
10–12 mo: durable books with pictures,
nesting cups, push-pull toys, and
building blocks
Parallel (along side but not interactive) Dolls, housekeeping toys, books, singEnhances locomotion skills (gross and
a-long tapes, rocking horses, pull
fine), language development,
toys, finger paints, clay, large piece
imitates adult roles
puzzles, blocks, and balls
Associative (interactive and
cooperative but defines own rules)
Promotes fine/gross motor skills,
contact with playmates, and
encourages imagination
Tricycle/big wheels, wading
pools/sandboxes, gym sets,
blocks/puzzles/simple crafts,
crayons/paints, puppets/dolls stuffed
animals, imaginary items, and ageappropriate electronic games
(Continued text on following page)
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Age Group
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Use of Play for Children
Age Group
Type and Purpose of Play
Safe Toys
School Age
Competitive and complex-”team” play
Develops social skills through learning
rules and rituals of games and
continued refinement of fine/
gross motor skills
Board games, card games, music and
art, athletic activities, team activities, movies, and interactive video
games
Adolescent
Group/peer type play
Continues to enhance social skills and
roles, cognitive skills, and wellness
with sports or exercise activities
Sports, camping, video and computer games, radios, disc players,
phones, models, and collectibles
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Safe Hospital Bed/Crib Choices
Premature infants and newborns
Infants/young toddler
Toddlers/young preschoolers
Older preschooler to adolescents
Isolette or radiant warmer
Open crib
When child is left alone, use the enclosed bubble-top crib
Hospital bed with rails in lowered position
In general, bed/crib selection based on child’s age, developmental abilities, LOC, and
health conditions
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Use of Play for Children (Continued)
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123
Quick 10-Minute Assessment
Look At the Child and Environment
■ Is the child THERE? ALIVE?
■ In the crib or hanging from the sides? (Children can do
amazing stunts!)
■ Are the parents with the child?
■ What type of equipment is at the bedside?
Begin with Safety
■ Is the child breathing?
■ Do you observe any signs of distress? (Follow the ABCs you
learned in CPR)
■ What is the child’s color? (pale, red, blue …)
■ Is the child on a monitor? (What is the rate & pattern?)
■ Any IVs? (Note type, rate, & site)
■ Note last set of vital signs (Include other findings based on
child’s condition, PIC line, chest tubes, and so on) Abnormal?
If so, check again.
■ When was the last time the child voided?
■ Do you observe anything unusual that needs immediate
interventions? DO IT NOW!
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Check the Equipment
■ Are the monitor and respirator alarms set at the proper
limits?
■ Is the 02 set up correctly? Does it work?
■ Is the suction equipment set up and ready to be used? TEST
IT!
■ Is there an appropriate resuscitation bag with the proper size
mask?
■ Is the correct equipment at the bedside for the child on
seizure precautions?
■ Are the crib rails up?
■ Are restraints applied correctly? (Is there an order for the
restraints?)
■ Are tabletops and crib or bed cleared of unsafe articles?
Focus Assessment on Area of Major Diagnosis
■ This initial assessment takes about 2–3 minutes.
■ Do the same initial assessment on all patients then return to
do the more in-depth assessment.
■ If the patient is in critical condition do the in-depth
assessment NOW!
124
Copyright © 2006 by F. A. Davis.
Normal
Moderate Impairment
Severe Impairment
Quality of Cry
Strong normal tone
or content and not
crying
Whimpering or
sobbing
Weak, moaning, or
high pitched
Reaction to
Parent Stimulation
Cries briefly, then
content and not
crying
Cries off and on
Continual cry or
hardly responds
State Variation
If awake, stays
awake; if asleep
and stimulated,
quickly wakes
Eyes close briefly
then awakens, or
wakes with
prolonged
stimulation
Will not rouse or falls
to sleep
Color
Pink
Pale hands, feet or
acrocyanosis
Pale or blue or gray
or mottled
Hydration
Skin warm and dry,
eyes and mouth
moist
Skin and eyes
normal and
mouth slightly dry
Skin doughy or
tented and eyes
sunken and dry
Response to
Social Overtures
Smiles; alert
Brief smile; or
briefly alert
No smile, anxious
face, not alert
From McCarthy PL, Sharpe MR, Spiesel SZ, et al. (1982). Observation scales to identify serious illness in febrile children.
Pediatrics; 78: 802.
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Observation
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Quick Evaluation of Sick Child
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Toddler
Important Aspects
Examples
Trust is developing; communicates
through coos, smiles, and cries at
first. First words around 8–9 mo.
Understands simple one word
commands at 1 yr. If primary
caregiver is comfortable, many
times the infant is calm and
trusting. Allow infant to be held by
caregiver as much as possible.
Sense of self and being independent
is becoming important;
understands simple two- and
three-word commands. Has 300
word vocabulary. Short attention
span of 1–5 minutes.
Provide gentle touching; firm
holding, and smiles to infant.
Speak to primary caregiver first. If
not contraindicated, offer pacifier
and use security blankets and
stuffed animals.
First, direct eyes and questions to
caregiver. Assume eye level of
child. Ask simple questions with
appropriate choices such as
“would you like to sit on your
mothers lap or up on the table?”
Use child’s language for specific
words in short and simple
sentences. Be attentive to
nonverbal cues. Use puppets and
dolls.
(Continued text on following page)
126
Age Group
Infant
Copyright © 2006 by F. A. Davis.
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Communication with Child and Family
Copyright © 2006 by F. A. Davis.
Age Group
Examples
Developing a concept of self;
understands simple sentences.
Has 900 words in vocabulary. Let
children know that they did not
cause the illness. Prepare child for
procedure right before the
treatment.
Assume eye level of child. Provide
appropriate choices. Offer
appropriate medical equipment for
play to reduce fear of equipment.
Use concrete sentences. Allow
child to ask questions.
School-Age
Interested in achievement; get child
to help you. Understands most
mature thoughts especially when
allowed to manipulate and see
objects.
Show the child equipment and use
clear simple instructions. Use
teaching aids and explain what
you do.
Adolescent
Transition between childhood and
adulthood; begin conversation
with them first then ask questions
of caregivers. Verify with
adolescent that they understand.
Can use brochures and videos.
“Would you like to have your
mother leave the room while I
examine you?” Provide privacy
and ensure confidentiality.
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Important Aspects
Preschooler
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Copyright © 2006 by F. A. Davis.
Subjective Assessment by Age Group
Infant (Per parent)
■ Chief complaint and HPI
■ Past history including
■ Prenatal history
■ Natal history (type birth)
■ Postnatal (with APGAR)
■ Allergies
■ Developmental milestones
■ Immunizations, safety issues
■ Nutritional intake (type, amount)
■ Sleep
■ Family history
■ Review of systems
Young child (Per parent and child)
Same as infant plus:
■ Play/activity
■ Personality
■ Fluid intake
Older child (Per child)
■
■
■
■
■
■
■
■
■
■
Chief complaint and HPI
Past medical history
Immunizations
Safety issues
Allergies
Nutritional intake
Family history
Social history, school achievements, play
Sleep
Review of systems
All children
Include type of housing, others in household, car seat and
smoke detector use, type of home heating, pets, family cultural
beliefs and practices.
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129
Systems Approach to Assessment
Although the systems approach works well and is often used in the
documentation of your findings, remember you must adapt your
method to the individual child!
HEENT
■ Eyes (redness, drainage, alignment)
■ Ears (response to sound, pulling at ears)
■ Mouth (excessive drooling, white patches in mouth)
Neuro
■ Level of alertness, affect, and responsiveness (awake, verbalizes,
awareness of surroundings, lethargic, obtunded, etc.)
■ Pupil check (darken room before trying to check, simultaneous
closing of eyelids, movements of eyes—any deviations to right or
left, color of sclera and conjunctiva, any drainage, visual acuity)
■ Movement of extremities (involuntary, voluntary, on verbal
command—for older child, moves in response to painful or other
stimuli, uncoordinated movements, twitches, tremors)
■ Hand grasps and pedal pushes (equality, remember you need to
adapt to developmental age) Reflexes—deep tendon reflexes,
presence or absence of newborn reflexes
■ Speech (clear, slurred, etc.)
■ Signs of seizure activity (describe type, how often, when, etc.)
■ Nuchal rigidity
■ Head circumference and size of fontanels (adapt to the
developmental age)
Respiratory
■ Inspect shape and contour of chest (expose the patient’s chest to
get a good look! Posture, spinal curvature, any equipment such
as chest tubes—if present, describe site, type, etc.)
■ Palpate expansion of chest for full and equal excursion (Inspect
for retractions, unequal expansion, etc.)
■ Respirations—easy, quiet, unlabored? Abdominal breathing?
(Children are often abdominal breathers until 6–7 yr)
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■ Auscultate the lungs from the top to the bottom, front and back
and laterally, include over the neck and trachea (compare right
and left sides, abnormal sounds—describe)
■ Does child breathe through nose or mouth (any drainage? if
present describe amount, color, and consistency)
■ Note Pulse oximetry (%02 saturation)
Respiratory Equipment
■ Ventilator—start at the nearest point to the patient—ET or trach
and work distally toward the machine
■ Size of ET or trach tube, whether tube is cuffed, amount of air in
cuff for seal, whether seal is intact, appearance of trach site, tube
placement, equality of bilateral lung expansion, quality and
equality of breath sounds, tubing and integrity of connections
■ Make sure there is no water in the tubes, know tidal volume,
measure O2 concentration
■ Note settings your patient is on—check the system pressures—
any change needed? Recheck all settings and alarms. Is the alarm
on?
■ Suction the patient, if needed. Observe the patient’s tolerance to
the procedure and type and amount of secretions
■ Check other O2 equipment such as croup tents, etc. Do you have
the right set-up? Proper concentration of O2? Water in containers
that should have water? Patient’s tolerance to the equipment? Is
there any cyanosis?
Cardiovascular
■ Inspect and palpate the point of maximum impulse (PMI)
Auscultate the heart sounds. What is rate and rhythm? Run a
strip if you can. Check the P, QRS, and T waves—any
abnormalities? Are all peripheral pulses present and equal? Any
edema? (Check dependent areas like the sacral area)
■ Any signs of dehydration? (Sunken fontanels, lethargic, sunken
eyes, mucous membranes, etc.) Overall perfusion? (Skin warm,
dry and pink? Or cool, clammy, mottled?) Nail beds—(Good
capillary refill, pink, etc.?)
■ Check IV sites for signs of infiltration, phlebitis, etc., type and
rate of IV, infusion pump, etc. Hemodynamic monitoring: various
line—(Note the reading, equipment, sites, and dressing)
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131
Temporal
Carotid
Apical
Brachial
Aortic
area
Tricuspid
area
Pulmonic
area
Mitral or
apical
area
Femoral
Radial
Popliteal
Dorsal
pedis
Posterior
tibial
Auscultation areas and peripheral pulses.
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GI
■ Start from nose and mouth and work down. NG tube (Inspect
for patency, how long has it been in, any suctioning-type,
any drainage—describe odor, amount, color, consistency, pH,
quaiac, and so on)? Any other type of GI drainage? Abdomen
(Inspect, auscultate bowel sounds in all four quadrants,
palpate and percuss for size, consistency [soft or firm],
distention, rigidity, pain [location, intensity, quality]). Stool—
inspect for amount, color, consistency, guaiac, reducing
substance, when did child last have one? To decrease ticklish
or tense sensation, have child place feet flat on bed or table
with knees elevated and place child’s hand under your hand
as you palpate and percuss
GU
■ Foley (Describe type, when inserted, does it need to be
changed?). Foley care? Any urine? (What does it look like—
color, clarity, sediment or blood present? Test it for—specific
gravity, glucose, pH, etc.) Do you observe any urethral, penile,
vaginal discharge Circumcised? Determine weight of diaper: 1
g 1 cc (first weigh dry diaper and deduct weight of dry
diaper)
Skin
■ Look at it!! All of it.
■ Rashes, lesions—location, pattern, size, color elevation,
blanching? Breakdown?? Petechiae, purpura, bruising?
■ General skin condition—dry, oily, itchy, scaly? Skin turgor?
Lice? Color of the skin, any cyanosis, temperature, moisture?
■ Note dressings (dry and intact??)
■ Note mucous membranes (hydration, color)
■ Tongue (is it moist?)
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133
Musculoskeletal
■ Assess while doing other systems
■ Note if child is walking, sitting, or turning, ROM in all joints
■ Check spinal curvature and mobility, sacral dimples or tufts
of hair
■ Note strength, symmetry, and movement of extremities
Safety Education Topics for Specific Age Groups
Infant
Toddler/Preschooler
School age
Adolescent
Car seats. Water temperature (water
heater setting lower than 130F),
smoke detectors, bath safety
Car seats, pedestrian safety, water
safety, medications, and household
poisons
Pedestrian safety, bicycle helmets, seat
belts, no firearms in household, water
safety
Auto safety, alcohol/drug use,
occupational injuries, no firearms in
household
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MEDS/
ACUTE
Copyright © 2006 by F. A. Davis.
5 Rights of Drug Administration
■
■
■
■
■
Right Drug
Right Dose
Right Time
Right Route
Right Patient
Determining Dosage and Route
■ Variations based on age, weight, body surface area (BSA), and
maturity of kidneys and liver
■ Physician orders, dosage, and route
■ Nurse checks for safety of dosage and route
Methods to Determine Safety of Dose
Dosage Based on Body Weight
■ Determine child’s weight in kg
■ Establish safe dose from pharmacy text
■ Calculate dose using weight
Body Surface Area (BSA)
■ Use nomogram to determine where straight line connects
height and weight levels and bisects the BSA
■ Divide the BSA in meters by 1.7
■ Multiply the quotient from step 2 by the adult dose
Administration of Medication
■ Check for drug allergy history prior to administration
■ Check ID band; do not ask child to verbally identify himself;
child may say “yes” to any name or give false name to avoid
taking medication; do not use name card on bed to ID
child—children may switch beds
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135
■ Give choices when possible—”would you like to take your
medicine with water or juice?”
■ Ask parent for suggestions regarding how child prefers to
take medication
■ Allow parent to give medication if child prefers—be sure to
observe while entire dose is administered
■ NEVER leave med at beside
Routes for Medication Administration
Oral Route (by mouth)
■ Use tool that ensures accurate measurement: calibrated
dropper, syringe with needle removed, or plastic measuring
cup
■ Take care to prevent aspiration—hold child’s head up and
administer liquids to infant by carefully using a syringe or
dropper to place small amounts of med into infant’s cheek,
near back of mouth or by putting med into nipple for infant to
suck. Be prepared to suction med back into a small syringe for
oral administration if infant does not suck nipple
■ Do not dilute med in formula or large amount of liquid that
infant may not consume
■ May use small amount of flavored syrup to disguise
unpleasant tastes
Nasogastric (NG), Orogastric, or Gastrostomy Route
■ Crush pills finely to prevent clogging of tube
■ Check tube placement and infuse slowly
■ After med administration, flush line with water to ensure med
has cleared tube and to prevent clogging
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MEDS/
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Copyright © 2006 by F. A. Davis.
Optic Route (eye)
■ Ensure that med is room temperature
■ Drops—Place med in conjunctival sac; apply slight pressure to
inner puncta for 1 minute to keep drops from draining into
nose
■ If child is uncooperative, immobilize child’s head, place
drop(s) over inner puncta—med will drain into eye when
child opens his eye.
■ Explain to child that med may be tasted
■ Ointment—apply from inner to outer canthus
Otic Route (ear)
■ Ensure that med is room temperature
■ Position child with affected ear up—maintain position for one
full minute after administration of med
Child 3 yr, pull pinna down and back
Child 3 yr, pull pinna up and back
Nasal Route (nose)
■ Ensure that med is room temperature
■ Drops—Tip head back—may use towel roll between shoulders
of small child—maintain position for one full minute after
administration of med
■ Spray—Child should be seated with head up
Rectal Route
■ Suppository may be moistened with water or water soluble
jelly
■ Note that children usually consider this to be an invasive
procedure—drape child to provide privacy
■ Position child on left side
■ Insert rounded end of suppository gently into rectum
■ Hold child’s buttocks together for 5 minutes to avoid expulsion
of med
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137
Intramuscular (IM), Subcutaneous (SQ), Intradermal Route
■ Use small syringe to ensure accurate measurement
■ Use proper needle length for size of child and route
of administration (needle usually not more than
1 inch)
■ Do not draw up air bubble (clearing med from the
syringe’s dead space may result in very small dose
being inaccurate)
■ Anticipate resistance from child—enter room with
assistant to immobilize child if needed
■ Do not ask parent to immobilize child
■ Ask older child about preference of administration site
■ Tell child that is it okay to cry
■ Complete procedure as quickly as possible
■ Offer bandage after administration
■ Praise child’s efforts
Intravenous (IV) Route
See comments regarding syringe size and clearing syringe’s
dead space under Intramuscular Route
If not specified in med order, consider desired effect and stability
of med to determine whether to administer:
■ Slow IV push (over several minutes)
■ Retrograde infusion (med is injected into a Y-port after
temporarily clamping IV line below Y-port)
■ Instilling med into mini IV chamber such as Buretrol
or using syringe pump
MEDS/
ACUTE
Page 138
Preferred Site
Newborn &
Young Infant
Infant
Vastus lateralis
Toddler
Vastus lateralis or Ventrogluteal
(relatively free of major nerves and
blood vessels—large muscle with little
subcutaneous tissue, less painful than
vastus lateralis and easily accessible)
Deltoid (faster absorption rates than
gluteal and less painful; limit to 1 mL)
or ventrogluteal
Older Children
Vastus lateralis
Needle Length/Gauge
5/8 inch*/24–25 G no more
than 0.5 mL
5/8–1 inch*/23–25 G no
more than 1 mL
1 inch*/22–23 G no more
than 1 mL
1 inch*/22–23 G no more
than 1.5–2 mL
* Consider amount of body fat when selecting needle length
Notes: Use dorsogluteal in children older than 3 years because it takes more than a year of walking to
develop larger muscle mass appropriate for this route. Administer EMLA cream or topical vapocoolant spray
to injection site prior to giving the injection to decrease discomfort.
138
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Age Group
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IM Injection Sites
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139
Pediatric Injection Sites
Greater
trochanter
Femoral nerve,
artery,vein
Tensor
fascia latae
Sartorius
Vastus
lateralis
Rectus
femorus
Vastus lateralis.
j
(gluteus medius)
Anterior superior
iliac spine
Posterior
iliac crest
Tensor
fascia
latae
Palm over
greater
trochanter
Gluteus
maximus
Ventrogluteal.
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Clavicle
Acromion
process
Deltoid
Deltoid.
Intravenous Maintenance Fluids
Calculations by Body Weight
10 kg in weight
11–20 kg in weight
20 kg in weight
100 cc per kg of weight cc for
24 hours
1,000 cc 50 cc/kg for each kg
10 kg cc for 24 hours
1500 cc 20 cc/kg for each kg
20 kg cc for 24 hour
Surface Area – Fluid maintenance requirements in mL/day BSA in m2
1500 mL/day/m2 (1500–2000 mL/m2/day)
24 hour total divided by 24 hours rate in milliliters per hour
Maintenance Sodium: 2–3 mEq/kg/24 hours
Maintenance Potassium: 1–2 mEq/kg/24 hours
For initial IV, potassium is generally added to the IV fluids AFTER
the child voids
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141
To Calculate IV Rates
Total Volume Drop Factor ÷ Infusion Time in Minutes Drops/minutes
Microdrip Tubing 60 gtts/mL used in volume control chamber
(Buretrol, Soluset, Volutrol) in pediatrics
Macrodrip Tubing 10, 20, 15 gtts/mL depending on brand of
tubing—may be used for adolescent
Key Monitoring for Child on Parenteral Nutrition
■
■
■
■
Daily weight
Weekly height/length
Hourly intake and output amounts
Every 8 hours note urine specific gravity, glucose, and protein
Peripheral Intravenous Access In Children
Comments Related
to Children
Needle
Gauge
Available Sites
Veins are more fragile
External jugular and scalp
so protect with tape,
veins: frontal, superficial
arm board, or surgical
temporal, posterior
netting. Choose site
auricular; upper
that will not interfere
extremities veins: dorsal
with activity for specific
hand, radial vein of wrist,
age group. Use EMLA
anterior ulnar-forearm,
cream, Fluori-Methane
median cephalic-lateral
vapocoolant spray, etc.,
antecubital fossa, median
for nonemergent
basilica-medial antecubital
insertion.
fossa; veins of the lower
During infusion, hang
extremity: superficial
4 hours’ worth of
veins of dorsum of foot,
IV fluid at any one
saphenous vein anterior
time (to prevent fluid
and superior to the medial
overload). Check site
malleolus of the ankle,
frequently for signs of
and along proximal length
infiltration or phlebitis
on medial foreleg
20–24 G
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Median
cephalic v.
Median
antebrachial v.
Median
basilic v.
Supraorbital v.
Cephalic v.
Frontal v.
Umbilical v.
Basilic v.
(newborn only)
Great
saphenous v.
Superior
temporal v.
Posterior
auricular v.
Jugular v.
Dorsal
venous
arch
Cephalic v.
Median
marginal v.
5th interdigital v.
Dorsal
arch
Basilic v.
Preferred sites for peripheral intravenous access and venipuncture in infants and young children.
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Pediatric I.V. Sites
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143
Central Venous Access Devices (CVADs)
Examples
of Types
Comments Related to Use
and Contraindications
Peripherally Inserted
Central Catheter
(PICC)
Used for long-term IV antibiotics,
chemotherapy, TPN, or blood
products; contraindicated with
inadequate veins, bleeding
disorders, immunosuppression,
noncompliance, trauma to
extremity, severe burns, or
infections
Total Implantable
Used for long-term IV fluids,
Device—Port-A-Cath
medications, blood products, TPN,
and venous blood sampling and
analysis; use 19–22 gauge rightangled needle with topical
anesthesia to access and typically
monthly flushing with heparinized
saline solution; same type of
contraindications as in PICC and not
used in child requiring less than 6
mo of intermittent IV therapy
External/Tunneled
Long-term central venous catheter
Catheter—Broviac,
used for same purposes as
Hickman, Groshong
implantable device but better suited
in very small children and infants;
requires site care and frequent
flushing with heparinized saline or
saline solution
Complications related to CVADs include infections, phlebitis,
thrombosis, occlusions, breaks, migration, or accidental
removal
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1 yr old
Assess
responsiveness
Open Airway and
Assess Breathing
Perform Rescue
Breathing begin
with 2 breaths
Assess Pulse
Provide Compressions
Compression/
Ventilation Ratio
Count Sequence
1–8 yr old
8 yr old
If collapses suddenly and known cardiac
condition—activate EMS; otherwise
activate after 1 min resuscitation
Determine
unresponsiveness
then activate EMS
No trauma suspected—head-tilt/chin-lift position. If trauma, use jaw
thrust only. Look listen, feel 10 sec
1 breath per 3 sec (20/min)
1 breath per 5 sec
(12/min)
Brachial or femoral
1 finger below
intermammary line
with 2 fingers
depress chest
1/2–1 in—100/min
Carotid
Heel of hand on
lower half
sternum
and depress
chest 1–1 1/2
in—100/min
5:1; pause for ventilation if patient is not
intubated
1,2,3,4,5
1&2&3&4&5
Heel of one hand
on top of other
hand on lower
half sternum and
depress chest
1 1/2–2 in—
100/min
15:2
1 & 2 & 3 & 4 & 5…
Adapted from the American Heart Association. (2002). PALS Provider Manual. American Heart Association, pp. 43–80.
144
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Key Points for Pediatric Cardiopulmoary Resuscitation (CPR)
1 yr old
Conscious Victim
Assess breathing to determine if
ineffective or no strong cry
1–8 yr old
8 yr old
Ask, “Are you choking?”–Can the child
speak or cough? May demonstrate
universal choking sign
Perform up to 5 subdiaphragmatic
Give 5 back blows; then 5 chest
abdominal thrusts (Heimlich)
thrusts
Repeat until obstruction relieved or becomes unconscious
Child Becomes Unconscious
Place child on back; active EMS after 1 min rescue effort
145
Open airway and do finger
Open airway, if see foreign body
sweep
then remove
Give rescue breaths, if airway blocked, reposition head according
to age requirements, try rescue breaths again
Perform up to 5 subdiaphragmatic
Give 5 back blows; then 5 chest
abdominal thrusts
thrusts
Repeat steps until foreign object is removed
Unconscious Victim
Gently shake to determine
“Are you okay?”
alertness level
If unresponsive, activate EMS after 1 min rescue effort
Proceed as outlined above and in CPR
Mouth-to-mouth-nose seal
Mouth-to-mouth seal
Try rescue breath, if needed reposition & try again
Adapted from the American Heart Association. (2002). PALS Provider Manual., American Heart Association, pp. 43–80.
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Key Points for Pediatric Choking – Foreign Body
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Defibrillation Guidelines
Paddle Size
Paddle Placement
Energy Dose
4.5 cm for infants; 8–13 cm for children.
Use largest electrode size to have good
chest contact and separation of electrodes
One paddle on right upper chest below
clavicle and other paddle to the left of
nipple in anterior axillary-line; heart should
be situated between paddles
2 Joules/kg for initial defibrillation with
2–4 Joules/kg for all subsequent attempts;
for cardioversion, use 0.5–1 Joules/kg with
2.0 Joules/kg for all subsequent attempts
Bradycardia in Children:
Definition: “too slow” for age; HR 60/min in infant and young
child with evidence of poor perfusion
Causes: Hypoxemia (most common cause), hypothermia, head
injury, heart transplant, toxins/poisons/drugs
Treatment: Assess ABCs, ensure patent airway, monitor vital signs,
attach ECG monitor, start IV/IO and oxygenation per order/protocol,
treat cause
Common Medications Used: Oxygen, epinephrine, atropine
Tachycardia in Children:
Definition: “too fast” for age; rapid heart rate associated with shock
and hemodynamic instability
Causes: Hypoxemia, hypovolemia, hyperthermia, electrolyte
disturbances, tamponade, tension pneumothorax,
toxins/poisons/drugs, thromboembolism, pain
Treatment: Assess ABCs, if no pulse-initiate CPR, if pulse
present–oxygenate, ventilate, and follow orders/protocols, treat
cause
Common Medications Used: Oxygen, amiodarone, procainamide,
lidocaine, adenosine, may also use vagal maneuvers or
cardioversion depending on type of tachycardia
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147
Pulseless Arrest in Children:
Definition: Complete collapse confirmed by ECG in more than
one lead
Causes: Hypoxemia, acidosis, hypovolemia, tension
pneumothorax, cardiac tamponade, electrolyte imbalance, drug
overdose, and embolism
Treatment: Determine pulselessness and begin CPR
Ventricular fibrillation or Pulseless ventricular tachycardia:
Defibrillation up to 3 times, continue CPR, secure airway,
hyperventilate with 100% oxygen, secure IV/IO, administer
medications such as amiodarone, lidocaine, magnesium per
protocol.
Asystole/Pulseless Electrical Activity: CPR, secure airway and
IO/IV, hyperventilate with 100% oxygen, administer epinephrine
per protocol and treat cause.
Pediatric Trauma Score
Clinical
Assessment
Child Size
Airway
Score 2
20kg
Normal
90 mmHg
Systolic
Blood
Pressure
Awake
Central
Nervous
System
Open wound None
Skeletal
None
Score 1
10–20 kg
Maintainable
50—90 mm Hg
Score 1
10 kg
Not
maintainable
50 mmHg
(no pulse)
Obtunded/loss of
consciousness
Coma,
decerebrate
Minor
Major
penetrating
Open/Multiple
fractures
Closed fracture
From Ford EG, Andrassy RJ. (1994). Pediatric Trauma Initial Assessment and
Management. Philadelphia: W.B. Saunders, p. 112.
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Cardinal Signs of Respiratory Failure
■
■
■
■
■
■
Restlessness/Altered LOC
Tachypnea
Tachycardia
Evidence of ↑ Work of Breathing
Cyanosis
Diaphoresis
■
■
■
■
■
Physical signs of abuse/neglect reported by child
Repeated ED visits/previous history of abuse
Parents blaming siblings for injury
Inappropriate response to injury by child/caregiver to injury
Inconsistency between physical findings and cause of injury or
injury and child’s development
Recognizing Abuse/Neglect in Children
Emergencies Related to Diabetes
Causes
Symptoms
Hypoglycemia
Hyperglycemia
Too much insulin, delayed food
intake, exercise without
adjustment
Shaky, weak, sweaty, hungry,
dizzy, light-headed,
palpitations, visual changes,
gait disturbances, changes in
affect, confusion, slurred
speech, sleepiness,
unconsciousness, seizures
Stress, infection,
too little insulin
Blood
Glucose
Levels
60 mg/dL
Treatment
Give glucose, IV/PO
148
Increased thirst,
increased
urination,
weight loss,
increased
appetite,
decreased
energy level
Fasting: 240
mg/dL
Random: 300
mg/dL
Give IV fluids,
insulin, K
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149
General Types of Seizures
Obtain Seizure History: type, typical frequency, description and
frequency of corresponding events, auras experienced before
seizure, and any specific meds
Type
Types of Partial:
Simple
Complex
Types of
Generalized:
Absence (petit
mal)
Clonic
Tonic
Tonic-clonic
(grand mal)
Description & Treatment
Confined to one hemisphere—change in
posture, hallucinations, or flushing, no
aura and LOC alteration. Use
anticonvulsants such as carbamazepine
and phenytoin to control seizures.
Starts in one focal area and spreads to
both hemispheres; consciousness not
completely lost—confusion, aura may
occur, postictal response. Use
anticonvulsants such as carbamazepine
or phenytoin to control seizures; may
need more than one drug.
Sudden onset, lasts 5–10 sec, loose
responsiveness but no falling, eyelids
twitching, lip smacking, no postictal
response; anticonvulsants/ketogenic
diet.
Opposite muscles contract/relax in
rhythmic pattern, may occur in one or
more limbs; use anticonvulsants.
Muscles maintain continuous contracted
state (rigid posture) with variable loss
of consciousness; use anticonvulsants.
Violent total body tonic then clonic
movements with aura and postictal
response, loss of consciousness.
Phenobarbital, carbamazepine,
phenytoin, or other similar drugs may
be combinations.
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General Types of Seizures (Continued)
Type
Atonic
Types of
Miscellaneous:
Febrile
Status Epilepticus
Description & Treatment
Drop and fall attack with loss of posture
tone. Must wear helmet and use
anticonvulsants.
Elevated temp leads to seizure activity
5 minutes in young infants and
children, generalized, transient and
nonprogressive. Treat underlying
illness/fever, diazepam PO, monitor for
neurological deficits.
Prolonged or repetitive seizures without
interruption lasting longer than 30
minutes that results in anoxia, cardiac
and respiratory arrest; loss of
consciousness. Assess airway,
breathing, circulation. IV glucose and
other drugs such as diazepam,
phenytoin, phenobarbital used to
control problem within 20–60 minutes,
correct metabolic problems, may start
midazolam drip, treat underlying
cause, establish maintenance
anticonvulsant drugs.
For All Seizures:
Do: Stay with child; call for help; move to flat surface out of
danger; position on side with head supported and clothing
loosened. Maintain patent airway; record seizure activity and
assess neurological status and vital signs; document time
started and ended, aura–if present, color change, presence
of incontinence, oral tissue damage (if any), postictal
(postseizure) response.
Do Not: Try to interrupt seizure or restrain child; use tongue
blades.
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151
Degree and Signs of Fluid Deficit (Dehydration) in Children
Common
Clinical
Signs
Mild (5%
loss of
body
weight)
Moderate
(5%-9% loss
of body
weight)
Skin
Pale, warm
Skin turgor
Normal
Eyes
Normal
Mucous
membranes
Anterior
fontanel
(if still open)
Heart rate
Slightly
dry
Normal
Normal
Increased
Respiratory rate
Blood
pressure
Capillary
refill
Mental
status
Normal
Normal
Increased
Slight
decreased
Slight delay
Urine
output
Normal
Alert but
may be
irritable
Decreased
Pale,
mottled,
cool
Decreased
Appears
sunken,
poor tear
production
Dry
Slightly
depressed
Irritable,
restless
Oliguria
Severe
(10% loss
of body
weight)
Mottled to
cyanotic,
cool
Markedly
decreased,
tenting
Sunken, no
tear
production
Very dry and
cracked
Sunken
Increased,
pulse often
not
palpable
Increased
Decreased
Delayed
(4sec)
Lethargic to
comatose
Oliguria to
anuria
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Calculation of Deficit Water & Electrolytes
■ Water Deficit % Dehydration Child’s Weight
■ Sodium Deficit Water Deficit 80 mEq/L
■ Potassium Deficit Water Deficit 30 mEq/L
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of
Pediatrics (17th ed.). Philadelphia: W.B. Saunders, p. 247.
Type of Dehydration Based on Electrolyte Deficits
Type of Deficit
Serum Sodium Level
Isotonic
Hypotonic
Hypertonic
130–150 mEq/L
130 mEq/L
150 mEq/L
Oral Rehydration for Mild to Moderate Dehydration
Use solution such as WHO solution or Rehydralyte:
■ 50 mL/kg over 4–6 hours—mild dehydration
■ 100 mL/kg over 4–6 hours-moderate dehydration
■ 10 mL/kg or 4–8 oz of ORS for each diarrhea stool
■ If vomiting: 5–10 mL every few minutes
Adapted from Behrman, p. 250.
Quick Restoration of Circulatory Volume:
■ If 10% dehydration—fluid boluses intravenously
■ 20 mL/kg of crystalloid solution such as normal saline over 20
minutes, or
■ 10 mL/kg of colloid solution such as 5% albumin
■ Continue as ordered until clinical status improved
Adapted from Behrman, p. 247.
152
Use
Route
Dose in mg
Adenosine
(3 mg/ml)
Drug
Antiarrhythmic especially
for SVT
Rapid IV, IO
Amiodarone
Hydrochloride
Antiarrhythmic—prevent
or treat Vfib, Vtach,
SVT especially artial F
Anticholinergic used for
bradycardia and to
restore normal heart
contraction during
cardiac arrest
Electrolyte used to
maintain cardiac
contractility, treat
hypocalcaemia,
hypomag.
Anticonvulsant used to
treat seizures and for
intubation
Rapid IV, IO
0.1–0.2 mg/kg/dose,
(maximum single dose 12 mg) repeat q 2–3 min
5 mg/kg/dose, (maximum
dose 15 mg/kg/day)
may infuse IV 20–60 min
0.01–0.02 mg/kg/dose, may
repeat q 2 minutes
(maximum dose 1 mg
children; 2 mg in
adolescent)
10–30 mg/kg/dose of 10%
Ca Chloride, use with
caution, not for asystole
153
Atropine Sulfate
(0.4 mg/ml)
CaChloride
10% (100 mg/ml)
Diazepam
(5 mg/ml)
IV, IO, ET
Slow IV, IO
Slow IV, IO
0.1–0.2 mg/kg/dose
(maximum single dose 5 mg in 5 yr, 10 mg in
5 yr)
(Continued text on following page)
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Selected Emergency Drug Information
Drug
Use
Route
Dose in mg
Dobutamine
(12.5 mg/ml)
Beta-adrenergic agonist
used to depress
myocardial
contractility
Beta-adrenergic
agonist–vasopressor in
cardiogenic or septic
shock or to maintain
renal perfusion
Adrenergic agonist,
sympathomimetic
used to treat asystole,
bradyarrhythmias, Vfib
See above
IV, IO infusion
2.5–15 mcg/kg/minute (see
drug insert for further
instructions)
IV, IO
2–20 mcg/kg/minute (see
drug insert for further
instructions and infusion)
IV, IM, IO
0.01 mg/kg/dose; this
concentration is first
drug of choice for
pediatric arrest
0.1–0.2 mg/kg/dose; second
and subsequent doses,
repeat 3–5 min (may also
infuse at 0.1–1
g/kg/minute)
Dopamine
(40 mg/ml)
Epinephrine
1:10,000
(0.1 mg/ml)
Epinephrine
1:1,000
(1.0 mg/ml)
IV, IO, ET
(Continued text on following page)
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Selected Emergency Drug Information (Continued)
Drug
155
Route
Dose in mg
Lidocaine (0.1 ml/
kg-10 mg/ml
concentration)
Antiarrhythmic
Use
Rapid IV, IO, ET
Na Bicarbonate
(1 mEq/ml)
dilute 1:1
with saline
Electrolyte used to
correct metabolic
acidosis
Slow IV, IO
Naloxone
(Narcan)
(1 mg/ml)
Narcotic antagonist used
for narcotic overdose
IV, ET, IO
0.5–1 mg/kg bolus;
(maximum dose 3
mg/kg) Infusion 10–50
g/kg/min of 20 mg/ml
solution
0.5–1 mEq/kg/dose;repeat
5–10 min only if
oxygenated and
ventilated 0.3 wt. kg base deficit efficient
dosing
5 yr: 0.1 mg/kg/dose; 5
yr: 2.0 mg/kg/dose;
repeat 2–3 min to 10 mg;
ET dose 2- to 10-fold
higher
Refer to pharmacological inserts and other resources for complete information regarding drug use, side
effects, contradictions, etc.
Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care, American
Heart Association; and Hay WW, Levin MJ, Sondhelmer JM, Deterding RR. (2005). Current Pediatric Diagnostic
Treatment (17th ed.). New York: Lange Medical Books/McGraw Hill, p. 324.
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Selected Emergency Drug Information (Continued)
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TOOLS
Copyright © 2006 by F. A. Davis.
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bmi/oobinaries.
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New Food Guide Pyramid for Children. Center for Nutrition
Policy and Promotion, U.S. Dept. of Agriculture,
www.mypyramid.gov.
Reif M. (2003). How to identify and manage preeclampsia.
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Roberts J. (2003). A new understanding of the second stage of
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Children Needing Specialized Health and Developmental
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Simpson K, & Creehan P. (2001). Association of Women’s Health,
Obstetric and Neonatal Nurses’ Perinatal Nursing (2nd ed.).
Philadelphia: Lippincott.
U.S. Preventive Services Task Force (USPSTF). (2005). The Guide
to Clinical Prevention Services. Silver Spring: Agency for
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31, 2005, from http://www.ahrq.gov/clinic/uspstfix.htm.
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labeling and provides new advice to postmenopausal women
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Nursing (2nd ed.). St. Louis: Mosby.
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Illustration Credits
Pages 5, 6, 25, 35, 36, 54, 84 from Dillon PM: Nursing Health
Assessment: A Critical Thinking, Case Study Approach. FA Davis,
Philadelphia. 2003
Pages 78, 79 from Ross Products Division Abbott Laboratories Inc.
Page 109 from Hay WW, et al: Current Pediatric Diagnosis &
Treatment (17th Ed.) New York: Lange Medical Books/McGraw-Hill.
2005
Pages 110, 152 from Behrman RE, Kliegman RM, Jenson TB:
Nelson Textbook of Pediatrics, 17/e. Philadelphia: W.B. Saunders.
2004
Page 112 from Hahn YS, et al: Head injuries in children under 36
months of age, Child Nervous System. 4:34, 1988
Page 120 from Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S.
The FLACC: a behavioral scale for scoring postoperative pain in
young children. Pediatric Nursing, 23(3): 293–297. Copyright 2002,
The Regents of the University of Maryland.
Page 125 from McCarthy, PL, Sharpe, MR, Spiesel, SZ, et al (1982).
Observation scales to identify serious illness in febrile children.
Pediatrics, 78:802
Page 147 from Ford EG, Andrassy RJ. Pediatric Trauma Initial
Assessment & Management, p.112, Philadelphia: WB Saunders.
(1994)
160
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Index
Note: Page numbers followed by “f” and “t” indicate figures and
tables, respectively.
A
Abortion, spontaneous, 41
Abruptio placentae, 44, 45f
Abuse, child, 148
Activity level
in newborn, assessment of,
97
postpartum, 90
Adenosine, 153
AIDS. See HIV
Amiodarone, 153
Amniotomy, 72–73
Apgar score, 69
Apnea monitors, 114
electrode placement for,
115f
Atropine sulfate, 153
Bowel, postpartal assessment,
86
BPP. See Biophysical profile
Bradycardia
in children, 146
fetal, 58
Breast, infection of (mastitis),
94
Breast self exam (BSE), 5–7, 5f,
6f
Breastfeeding
advantages to, 80
breast care during, 82
engorgement, 81
nutrition during, 81
positioning, 79f, 80
pumping and storing, 81
supply and demand, 81
B
Basal body temperature, fertility awareness and, 9
Bathing, newborn, teaching
tips, 99
Bed/crib choices, by age
group, 122
Biophysical profile (BPP), 51
Bishop’s score, 71
Bladder, postpartal status, 86
Blood pressure, pediatric,
normal ranges, 112
BMI. See Body mass index
Body mass index (BMI)
pediatric, calculation of, 109
Bottle feeding, teaching tips,
100–102
C
Calcium chloride, 153
Calendar method, of fertility
awareness, 9
Caloric requirements, for children, 109
Cancer. See specific types
Cardiac monitors, pediatric,
114
electrode placement for,
115f
Cardiopulmonary resuscitation
(CPR), pediatric, key points
for, 144
Cardiovascular health, promotion of, 16
160
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Cardiovascular system, assessment of, 130
heart sounds and peripheral
pulses, 131f
Catheters, pediatric suction,
114
Central venous access devices
(CVAD), 143
Cervical cancer screening,
ACOG/ACS guidelines for, 1
Cervical mucus, fertility awareness and, 9
Cervical ripening, 72
Cesarean birth, 75
postpartal assessment in, 91
vaginal birth after, 73–74
Child abuse, recognizing, 148
Children
caloric requirements for, 109
communications with,
126t–128t
developmental milestones
in, by age group,
105t–108t
pain in
developmental differences
in, 118
nursing interventions
related to management
of, 119
questions in assessment
of, 117
responses to illness/hospitalization, by age group,
116t–117t
safety education topics, 133
sick, quick evaluation of,
125
systemic assessment, 129
cardiovascular, 130, 131t
gastrointestinal, 132
genitourinary, 132
musculoskeletal, 133
neuromuscular, 129
respiratory, 129–130
respiratory equipment,
130
skin, 132
10-minute assessment of,
123–124
use of play for, by age
group, 105t–108t
Chlamydia, symptoms and
detection, 3t
Choking, pediatric, key points
for, 145
Circumcision, teaching tips,
102–103
Clonic seizures, 149
Colorectal cancer, early signs
of, 17
Coma scale, pediatric, 112
Communication
with child and family,
126t–127t
in newborn, teaching tips,
98
Condoms, 11–12
Contraception
barrier methods, 10–11
educating women on, 7
emergency, 15
fertility awareness methods,
8–9
hormonal methods, 11–14
contraindications to, 12
intrauterine system, 14–15
lactation amenorrhea
method, 10
permanent methods, 15–16
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Contraction stress test (CST),
50–51
CPR. See Cardiopulmonary
resuscitation
CST. See Contraction stress
test
CVAD. See Central venous
access devices
intramuscular, 137
sites for, 139f, 140f
intravenous, 137
sites for, 142f
nasal, 136
nasogastric/orogastric/
gastrostomy, 135
optic, 136
oral, 135
otic, 136
rectal, 136
subcutaneous, 137
D
Deep venous thrombosis, 95
signs of, teaching tips, 96
Defibrillation, pediatric guidelines, 146
Dehydration, pediatric
degree/signs of, 151
water/electrolyte deficit,
calculation of, 152
Delivery, estimated date of, 20
Depo-medroxyprogesterone
(DMPA), 14
Developmental milestones
0–1 year, 105
1–3 years, 106
3–6 years, 107
6–12 years, 108
12–18/21 years, 108
Diabetes
emergencies related to, 148
gestational, 49–50
Diaphragms, 10
Diazepam, 153
DMPA. See Depo-medroxyprogesterone
Dobutamine, 154
Dopamine, 154
Drug administration, 134–135
5 rights of, 134
routes of
determination of, 134
intradermal, 137
E
Eclampsia, 48
Ectopic pregnancy, 41
Electrode placement, pediatric
cardiac/apnea monitors, 115f
Electrolyte/water deficit, calculation of, 152
Emotional response,
postpartal
assessment of, 88
support for, 89
Endometrial cycle, 8
Endometritis, 94
Epinephrine, 154
Estrogen
contraindications to, 12
effects of, 11
Extremities, assessment of
in newborn, 97
in postpartal patient, 89
F
Family planning. See
Contraception
Fears, in children as response
to illness/hospitalization,
116–117
Febrile seizures, 150
162
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163
Fertility awareness methods,
8–9
Fetal heart tones (FTH),
Doppler placement for, 36f
Fetal monitoring
baseline heart rate
changes to, 58–62
evaluating, 56, 57f
continuous
external, 55f
internal, 56f
intermittent auscultation,
54–55
nursing responsibilities in,
54
Fetoscope, 54f
FLAAC pain assessment tool,
120t
Fluid deficit. See Dehydration
Food pyramid, 31f
Formula, infant, 100
Fundus
height of, 25f
by weeks of gestation, 24
massage of, 83f
postpartal assessment of,
84–85
G
Gastrointestinal system,
assessment of, 132
Genetic screening, in
newborn, teaching tips, 104
Genitourinary system, assessment of, 132
Gestational trophoblastic
disease, 41–42
Gonorrhea, symptoms and
detection, 3t
Grand mal seizures, 149
H
Health maintenance, in
newborn, teaching tips, 103
Heart rate, fetal
changes to baseline, 58–62
accelerations, 59, 59f
early decelerations, 59,
60f
late decelerations, 60–61,
60f
nursing interventions for,
62
variable decelerations, 61,
61f
evaluation of, 56
normal, 57f
Heart sounds, 131f
HELLP syndrome, 48–49
Hemorrhage, in postpartal
patient, 92–93
Hepatitis, symptoms and
detection, 3t
Herpes simplex virus
(HSV), 2
symptoms and detection, 4t
History(ies)
intrapartum, 52–53
pediatric, concerns by age
group, 128
prenatal health, 21–22
HIV, symptoms and detection,
4t
Hormonal contraceptives, 11
combined methods, 12–14
contraindications to, 12
Hormonal replacement therapy (HRT), 18
Hospitalization, children’s
responses to, by age group,
116–117
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HPV. See Human papillomavirus
HRT. See Hormonal replacement therapy
HSV. See Herpes simplex virus
Human papillomavirus
(HPV), 2
symptoms and detection, 3t
Hyperemesis gravidarum, 45
Hyperglycemia, 148
Hypoglycemia, 148
Hysteroscopic tubal sterilization, 16
Intravenous access sites, pediatric, peripheral, 141, 142f
Intravenous maintenance
fluids, calculations
by body weight, 140
of IV rates, 141
IUD. See Intrauterine device
K
Kegel exercises, 88
L
Labor
active phase (stage 1), 64–66
epidurals in, 66
expulsion (stage 2), 67–69
fourth stage, 76
induction of, 71–73
latent phase (stage 1), 64
monitoring contractions,
62–63
nursing care in, 63
placenta delivery (stage 3),
70
preterm, 46–47
systemic pain medications
in, 65
transition phase (stage 1),
66–67
Lactation amenorrhea method
(LAM), 10
LAM. See Lactation amenorrhea method (LAM)
Leopold’s maneuver, 35f
Lidocaine, 155
Lochia, 86
assessment of, 87
normal progression of, 85
Loss of control, in children as
response to illness/hospitalization, 116–117
I
Illness, children’s responses to,
by age group, 116–117
Immunizations
genetic and hearing screen,
teaching tips, 104
in newborn, teaching tips,
104
Infants
developmental milestones,
105
feeds, number/volumes, 109
food types, introduction of,
111
vital signs, 110
See also Newborns
Infection, in postpartal patient,
93–94
Injections
intradermal, 137
intramuscular sites, 138,
139f, 140f
intravenous, 137
sites for, 142f
subcutaneous, 137
Intrauterine device (IUD),
14–15
164
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M
Mastitis, 94
Menopause
hormonal replacement therapy in, 18
symptoms of, 17
Menstrual cycle, 7
postpartal return of, 85
Musculoskeletal system,
assessment of, 133
N
Naegele’s Rule, 20
Naloxone, 155
Neglect, child, 148
Neuromuscular system,
assessment of, 129
Newborns
breastfeeding of, 78f, 79–82,
79f
care of, teaching tips
bathing/skin care, 99
bottle feeding, 100–102
circumcision, 102–103
communication, 98
reportable symptoms, 104
safety and health maintenance, 103
sleep patterns, 98
umbilical cord care,
100
immediate care of,
68–70
nursery care of, 97
physical assessment of, 97
Nonstress test (NST), 50
NST. See Nonstress test
Nutrition
of children, caloric requirements, 109
food pyramid, 31f
in pregnancy, education on,
31
O
OCT. See Oxytocin challenge
test
Osteoporosis, prevention and
treatment of, 16
Ovarian cycle, 8
Oxytocin, in induction of labor,
71–72
Oxytocin challenge test (OCT),
50–51
P
Pain
developmental differences
in children related to,
118
FLAAC assessment tool,
120t
nursing interventions
related to management of,
119
questions in assessment of,
117
Parenteral nutrition
calculations
by body weight, 140
of IV rate, 141
keys for monitoring child on,
140
Pediatric coma scale, 112
Pediatric trauma score, 147
Perineum, postpartal assessment, 87
Petit mal seizures, 149
Pitocin. See Oxytocin
Placenta previa, 42, 43f, 45
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Play, type/purpose of, by age
group, 121–122
Postpartum blues/depression,
89, 94–95
signs of, teaching tips, 96
Postpartum patient
breast assessment, 77
cesarean, assessment of,
91–92
complications in
hemorrhage, 92–93
infection, 93–94
education of, 77
in breastfeeding, 78–82
emotional response, assessment/support of, 88–89
laboratory data in, 91
nursing assessment of,
76–77
return of menstrual cycle in,
85
sexuality in, 85
uterine involution in, 83–84,
84f
Preconception counseling,
7
Preeclampsia, 47–48
Pregnancy
classification of medications
in, 31
common laboratory tests in,
26
complications in
abruptio placentae, 44f
eclampsia, 48
gestational diabetes,
49–50
HELLP syndrome, 48–49
hyperemesis gravidarum,
45
placenta previa, 42, 43f, 45
preeclampsia, 47–48
preterm labor, 46–47
vaginal bleeding, 42
delivery date estimating in,
20
early
diagnostic testing in,
27–28
education in, 28
establishing, 19
exercise in, 33
fetal surveillance in, 50–62
biophysical profile, 51
contraction stress test,
50–51
nonstress test, 50
hormonal changes in,
23
low-risk, prenatal visits,
scheduling of, 21
physiological changes in, 23
second/third trimester,
education in, 38–40
sexuality in, 34
teratogen exposure in, 30
trimesters of, 20
warning signs during,
34
weight gain in, 33
Prenatal visits
first
diagnostic tests for, 26
history taking in, 21–22
nursing care with, 24
patient education in
in early prenatal period
on discomforts/
reportable symptoms,
28t–29t
on exercise, 33
on nutrition, 31, 32f
166
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167
on sexuality, 34
on teratogen exposure,
30
on warning signs, 34
on weight gain, 33
in second/third trimester,
38
on discomforts/
reportable symptoms,
39t–40t
return
diagnostic tests for, 37
nursing care for, 35–36
scheduling, 21
Preterm labor, 46–47
Progestin
contraindications to, 12
effects of, 11
single agent preparations,
14
Pulse oximetry, pediatric, 114
Pulseless arrest, in children,
147
Pulses, peripheral, 131f
R
Rehydration, 152
Respiratory failure, cardinal
signs of, 148
Respiratory system, assessment of, 129–130
S
Safety
of drug dose, determination
of, 134
education topics, by age
group, 133
in infant/child assessment,
123–124
in newborn, teaching tips,
103
of toys, by age group,
121–122
Screening, cervical cancer,
ACOG/ACS guidelines for, 1
Seizures, general types of,
149–150
Separation anxiety, in children
as response to illness/hospitalization, 116–117
Serum pregnancy test, 19
Sexuality
postpartal, 85
in pregnancy, 34
Sexually transmitted diseases
(STDs), 2, 3t–4t
Skin
assessment of, 132
care of, in newborn, teaching tips, 99
Skin cancer, early
detection/prevention of,
17
Sleep patterns, in newborn,
teaching tips, 98
Sodium bicarbonate, 155
Status epilepticus, 150
STDs. See Sexually transmitted diseases
Suctioning, pediatric, 114
Syphilis, symptoms and detection, 4t
T
Tachycardia
in children, 146
fetal, 58
Teratogens, in pregnancy,
education on, 30
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Thrombophlebitis, 95
signs of, teaching tips, 96
Tonic seizures, 149
Toys, safe, by age group,
121–22
Trauma, score, pediatric, 147
Trichomoniasis, symptoms and
detection, 3t
Tubal ligation
hysteroscopic, 16
incisional method, 15
V
Vaginal birth after cesarean
(VBAC), 73–74
Vaginal bleeding, in pregnancy, 42
VBCA. See Vaginal birth after
cesarean
Venipuncture sites, pediatric,
142f
Vital signs
newborn, 97
pediatric, average ranges,
110
postpartum, 90
U
Ultrasonography, in establishing pregnancy, 19
Umbilical cord
care of, teaching tips, 100
prolapse of, 74
Urinary tract infection, in postpartal patient, 93–94
Urine output, pediatric, 110
Urine pregnancy test, 19
Uterus
infection of (endometritis),
94
involution of, 83
subinvolution signs, teaching tips, 96
W
Water/electrolyte deficit, calculation of, 152
Water requirements, pediatric,
110
Weight gain, in pregnancy,
33
Weight loss, at birth, 91
Weight management, promotion of, 16
Women, health promotion in,
16–17
nurses’ role in, 1
168
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